Byline: Laima Alam
Keywords: Cirrhosis, Hepatocellular carcinoma, Hepatitis B, Hepatitis C, Liver transplant.
Malignancy is emerging as the main aetiology of death in the modern world, with hepatocellular carcinoma (HCC) being the fifth most common cancer and the third most common cancer-related cause of death around the world. 1 Asia as well as northern and southern Africa have been reported to have the highest incidence of primary liver cancers, with the highest age-standardised incidence rate (ASIR) seen in eastern Asia, and the lowest in northern Europe. 2 Population bloom, aging, socio-demographic conditions, access to care and viral infections are the main attributable factors for the rising cancer burden in under-privileged communities. 3
While HCC incidence is higher in Asian and African countries, mortality from liver cancer has shown a growing trend in the more effluent societies, like the United States 4 and may be attributable to the changes in risk factors, like obesity, metabolic syndrome (MS) and alcoholism. 5 The 5-year relative survival rate is only 14% for HCC in the US and even lesser in under-developed countries. 6
In around three quarters of all HCC cases, the aetiological factor has been recognised as chronic infection with hepatitis C virus (HCV) or hepatitis B virus (HBV) or both. 7 Other risk factors listed include cirrhosis secondary to alcoholism, non-alcoholic fatty liver disease (NAFLD), which includes non-alcoholic steatohepatitis (NASH), tobacco, arsenic, cirrhosis of any aetiology, tyrosinaemia, several porphyrias, aflatoxin and oral contraceptive pills. 8
In Pakistan, the ASIR for HCC is 7.6 per 100,000 per year for the male population, and 2.8 for the females. 9 It has been reported that 60-70% of all HCC cases can be attributable to chronic HCV infection. This is in contrast to many other neighbouring Asian countries where chronic HBV is the main culprit. 9 Many of the local epidemiological studies are single-centre in approach, and comparative studies with application of international guidelines remain questionable for the local population as there is no national cancer registry available. 9
Despite the slowly decreasing mortality and morbidity secondary to other major carcinomas, the collective HCC burden is on the rise 10 and, therefore, needs robust research. The current study was planned to analyse the relation of demographics of HCC with its aetiology in order to analyse tumour characteristics in relation to anti-viral therapy and the presence of viral-deoxyribonucleic acid/ribonucleic acid (DNA/RNA), and the treatment modalities
Patients and Methods
The cross-sectional study was conducted at the Department of Gastroenterology, Pak Emirates Military Hospital, Rawalpindi, Pakistan, from January 1 to December 31, 2019. After approval from the institutional ethics review board, the sample was raised from among HCC patients who presented to the outpatient-department (OPD) or from the HCC multi-disciplinary team (MDT) discussions both retrospectively and prospectively.
Those included were patients aged 18-70 years with HCC diagnosed through triphasic contrast-enhanced computed tomography (CECT) scan and/or magnetic resonance imaging (MRI) or core biopsy. 11 Those excluded were patients outside the age range, patients lost to follow-up and those with...