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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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Kumar S, Nadda N, Quadri A, Kumar R, Paul S, Tanwar P, Gamanagatti S, Dash NR, Saraya A, Shalimar, Nayak B. Assessments of TP53 and CTNNB1 gene hotspot mutations in circulating tumour DNA of hepatitis B virus-induced hepatocellular carcinoma. Front Genet 2023; 14:1235260. [PMID: 37593116 PMCID: PMC10429180 DOI: 10.3389/fgene.2023.1235260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 08/19/2023] Open
Abstract
Background: Hepatitis B virus (HBV) infection is one of the major causes of chronic liver disease, which progresses from chronic hepatitis B (CHB) to fibrosis, cirrhosis, and hepatocellular carcinoma (HCC). Early detection and laboratory-based screening of hepatocellular carcinoma are still major challenges. This study was undertaken to determine whether the cancer hallmark gene signatures that are released into circulation as circulating tumour DNA (ctDNA) can be used as a liquid biopsy marker for screening, early detection, and prognosis of HCC. Methods: A total of 130 subjects, including HBV-HCC (n = 80), HBV-cirrhotic and non-cirrhotic (n = 35), and healthy (n = 15) controls, were evaluated for TP53 and beta-catenin (CTNNB1) gene hotspot mutations in ctDNA by Sanger-based cycle sequencing and droplet digital PCR (ddPCR) assays. Mutation detection frequency, percentage mutant fractions, and their association with tumour stage, mortality, and smoking habits were determined. Results: Sanger-based cycle sequencing was carried out for 32 HCC patients. Predict SNP Tools analysis indicated several pathogenic driver mutations in the ctDNA sequence, which include p.D228N, p.C229R, p.H233R, p.Y234D, p.S240T, p.G245S, and p.R249M for TP53 gene exon 7 and p.S33T for CTNNB1 gene exon 3. The TP53 c.746G>T (p.R249M) mutation was detected predominately (25% cases) by sequencing, but there was no dominant mutation at position c.747G>T (p.R249S) that was reported for HBV-HCC patients. A dual-probe ddPCR assay was developed to determine mutant and wild-type copy numbers of TP53 (p.R249M and p.R249S) and CTNNB1 (p.S45P) and their percentage mutant fraction in all 130 subjects. The TP53 R249M and CTNNB1 S45P mutations were detected in 31.25% and 26.25% of HCC patients, respectively, with a high mutant-to-wild-type fraction percentage (1.81% and 1.73%), which is significant as compared to cirrhotic and non-cirrhotic patients. Poor survival was observed in HCC patients with combined TP53 and CTNNB1 gene driver mutations. The TP53 R249M mutation was also significantly (p < 0.0001) associated with smoking habits (OR, 11.77; 95% CI, 3.219-36.20), but not the same for the TP53 R249S mutation. Conclusion: Screening of ctDNA TP53 and CTNNB1 gene mutations by ddPCR may be helpful for early detection and identifying the risk of HCC progression.
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Affiliation(s)
- Sonu Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Neeti Nadda
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Afnan Quadri
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Rahul Kumar
- Laboratory Oncology Unit (BRA-IRCH), All India Institute of Medical Sciences, New Delhi, India
| | - Shashi Paul
- Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Pranay Tanwar
- Laboratory Oncology Unit (BRA-IRCH), All India Institute of Medical Sciences, New Delhi, India
| | | | - Nihar Ranjan Dash
- Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Anoop Saraya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 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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Wen N, Cai Y, Li F, Ye H, Tang W, Song P, Cheng N. The clinical management of hepatocellular carcinoma worldwide: A concise review and comparison of current guidelines: 2022 update. Biosci Trends 2022; 16:20-30. [PMID: 35197399 DOI: 10.5582/bst.2022.01061] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common malignancy and the second leading cause of cancer-related mortality worldwide. This review is an updated version that summarizes comprehensive guidelines published from January 2001 to January 2022 worldwide with a focus on the clinical management of HCC. The electronic databases MEDLINE, the Chinese SinoMed, and the Japanese CiNii were systematically searched. A total of 22 characteristic guidelines for HCC management were ultimately included, including 1 international guideline, 11 guidelines from Asia, 5 from Europe, 4 from the America, and 1 from Australia. If guidelines were published in multiple versions, the most recent update was included, and surveillance, diagnosis, and treatment were compared. The composition of and recommendations in current guidelines on HCC varied, so these guidelines were regrouped and diagnostic and treatment algorithms were summarized graphically to provide the latest information to clinicians. The diagnostic criteria were grouped into 2 categories: a "Size-based pathway" and a "Non-size-based pathway". The treatment criteria were summarized according to different treatment algorithms, and mainstream treatment options were reviewed. Findings from comparison of current guidelines might help target and concentrate efforts to improve the clinical management of HCC. However, further studies are needed to improve the management and outcomes of HCC. More straightforward or refined guidelines would help guide doctors to make better decisions in the treatment of HCC in the future.
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Affiliation(s)
- Ningyuan Wen
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yulong Cai
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Fuyu Li
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hui Ye
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wei Tang
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,International Health Care Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Peipei Song
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nansheng Cheng
- Department of Biliary Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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