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.