High burden of hepatocellular carcinoma and viral hepatitis in Southern and Central Vietnam: Experience of a large tertiary referral center, 2010 to 2016

Comparative prognostic performance of staging systems for hepatocellular carcinoma: Evidence from a Vietnamese cohort study

BACKGROUND

Hepatocellular carcinoma (HCC), the sixth most common cancer and fourth-leading cause of cancer-related mortality globally, imposes a significant burden in Vietnam due to endemic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. Accurate prognostication is crucial for optimizing treatment and outcomes. Numerous staging systems exist, including the Barcelona Clinic Liver Cancer (BCLC), Hong Kong Liver Cancer (HKLC), cancer of the liver Italian Program (CLIP), Italian Liver Cancer (ITA.LI.CA), Japan Integrated Staging (JIS), Tokyo Score, and model to estimate survival in ambulatory HCC patients (MESIAH). However, their comparative performance in Vietnamese patients remains underexplored.

AIM

To compare the prognostic accuracy of seven HCC staging systems in predicting survival and identify the optimal model.

METHODS

This retrospective cohort study included 987 patients with HCC diagnosed at Nhan dan Gia Dinh Hospital, Vietnam, from January 2016 to December 2023. Patients were staged using BCLC, HKLC, CLIP, ITA.LI.CA, JIS, Tokyo score, and MESIAH. Overall survival was analyzed using Kaplan-Meier methods, and prognostic performance was evaluated via the area under the receiver operating characteristic (ROC) curve, Harrell’s concordance index, and calibration plots.

RESULTS

The HKLC and BCLC systems demonstrated the highest discriminatory ability, with area under the ROC curves of 0.834 and 0.830, respectively, at 12 months and 0.859 for both systems at 36 months. CLIP and ITA.LI.CA exhibited superior calibration, particularly at 36 months. The JIS system consistently showed the poorest discriminatory performance. Subgroup analyses revealed that HKLC maintained strong performance across different viral etiologies (HBV, HCV, non-B-non-C) and treatment modalities (transarterial chemoembolization, surgery, ablation).

CONCLUSION

The HKLC and BCLC systems showed superior prognostic performance for Vietnamese patients with HCC, supporting HKLC adoption in clinical practice.

Long-Term Survival and Prognostic Factors of Stereotactic Body Radiotherapy Following Transarterial Chemoembolization for Hepatocellular Carcinoma

BACKGROUND/AIMS

This study presents a detailed analysis of long-term survival and critical factors influencing the outcomes of hepatocellular carcinoma patients treated with stereotactic body radiotherapy (SBRT) and transarterial chemoembolization (TACE). Our findings provide reassurance about the potential of the combination of TACE and SBRT as an effective treatment strategy for patients with large liver tumors due to HCC.

METHODS

A prospective study was conducted on 42 patients with intermediate-stage hepatocellular carcinoma (HCC) at 108 Military Central Hospital between December 2018 and June 2024. Following a single session of TACE, each patient underwent SBRT 1 month later. The SBRT dose ranged from 27.5 to 48 Gy, delivered in 3-5 fractions. The patient survival analysis was conducted using the Kaplan-Meier method while examining prognostic factors influencing survival, which involved log-rank tests and Cox proportional hazards regression analysis.

RESULTS

Among the 42 patients (83.3% male), 34 patients (81.0%) had tumors measuring ≥ 5 cm. The median follow-up period was 32.2 months (4.5-65.1 months). The median overall survival (OS) was 32.6 months, with the respective 1-, 3-, and 5-year OS rates reported as 73.8%, 24.5%, and 19.6%. Furthermore, the median progression-free survival (PFS) was 16.6 months, with corresponding 1- and 3-year PFS rates of 71.4% and 19.0%. Factors linked to improved OS and PFS included AFP levels and treatment response based on Modified RECIST criteria. Additionally, multivariate analysis identified patient age, EQD2, and BED10 as significant predictors of better survival outcomes.

CONCLUSIONS

Our study provides evidence supporting the effectiveness and safety of combining TACE and SBRT as a treatment strategy for patients with large liver tumors due to HCC, instilling confidence in the future of HCC treatment. Positive prognostic factors included patient age, EQD2, and BED10.

Nonadherence to oral cancer chemotherapy in hepatocellular carcinoma: prevalence and predictive factors in Vietnam

PURPOSE

Standard oral cancer chemotherapy (OCT) or targeted therapy (OTT) has expanded the treatment methods for hepatocellular carcinoma (HCC). However, its principal nonadherence causes a reduction in efficacy. We aimed to evaluate the status of nonadherence and influencing factors among outpatient patients with HCC.

PATIENTS AND METHODS

In 2021, a prospective observational study was conducted on 384 patients with either old or newly diagnosed HCC treated with OTT. Nonadherence to OCT was determined using the eight-item Morisky Medication Adherence Scale, with a score < 6 points. The patients were finished with a six-month follow-up investigation by questionnaires.

RESULTS

54,8% of HCC outpatients were nonadherent to OCT, with a mean Morisky score of 5.19. They dropped out of the treatment mainly because of drug side effects, such as fatigue (72.4%), hand-foot syndrome (42.7%), diarrhea (38.3%), nausea (25%), insomnia (24.7%), abdominal pain (12%), and anxiety about these adverse events (65.9%). Additionally, financial difficulties and low relative copayments were significantly correlated with the noncompliant treatment of patients (OR = 2.29, 95% CI = 1.32-3.98, P = 0.003; OR = 4.36, 95% CI = 0.95-19.93, P = 0.039, respectively). Moreover, inadequate individual information about the clinical course, the art of treatment, and medication usage instructions were suggestive barriers to adherence to treatment (OR = 1.96, 95% CI = 1.08-3.55, P = 0.024; OR = 1.86, 95% CI = 1.1-3.14, P = 0.02; OR = 2.34, 95% CI = 1.29-4.26, P = 0.004, respectively). Finally, a low level of trust in doctors was an essential factor in nonadherence (Mean of the Anderson Trust in Physician Scale scores counted 38.12 vs. 43.97, respectively for non-adherence vs. adherence, P = 0.00001).

CONCLUSIONS

This study suggests a high rate of primary nonadherence to standard oral targeted therapy among HCC outpatient patients because of drug side effects, patient awareness of treatment, and lack of confidence in healthcare providers. Close supervision, proper medication instructions, appropriate dosage reductions, and comprehensive patient counseling might be necessary to control nonadherence.

Low HBV knowledge is associated with low HBV vaccination uptake in general adult population despite incentivization of HBV vaccination

BACKGROUND

Hepatitis B virus (HBV) vaccination in Vietnamese adults remains low and unequally distributed. We conducted a study on HBV-naïve adults living in Ho Chi Minh City, Viet Nam, to determine barriers associated with HBV vaccination uptake after removing the financial barrier by providing free coupons for HBV vaccination.

METHODS

After being screened for HBsAg, anti-HBs, and anti-HBc, 284 HBV-naïve study participants aged 18 and over (i.e., negative for HBsAg, anti-HBs, and anti-HBc total) were provided free 3-dose HBV vaccine coupons. Next, study participants' receipt of 1st, 2nd, and 3rd doses of HBV vaccine was documented at a pre-specified study healthcare facility, where HBV vaccines were distributed at no cost to the participants. Upon study entry, participants answered questionnaires on sociodemographics, knowledge of HBV and HBV vaccination, and related social and behavioral factors. The proportions of three doses of HBV vaccine uptake and their confidence intervals were analyzed. Associations of HBV vaccine initiation with exposures at study entry were evaluated using modified Poisson regression.

RESULTS

98.9% (281 of 284) of study participants had complete data and were included in the analysis. The proportion of participants obtaining the 1st, 2nd, and 3rd doses of HBV vaccine was 11.7% (95% Confidence Interval [95% CI] 8.0-15.5%), 10.7% (95%CI 7.1-14.3%), and 8.9% (95%CI 5.6-12.2%), respectively. On the other hand, participants were more likely to initiate the 1st dose if they had adequate knowledge of transmission (adjusted relative risk [aRR] = 2.58, 95% CI 1.12-5.92), adequate knowledge of severity (aRR = 6.75, 95%CI 3.38-13.48), and annual health-checking seeking behavior (aRR = 2.04, 95%CI 1.07-3.87).

CONCLUSION

We documented a low HBV vaccination uptake despite incentivization. However, increased vaccine initiation was associated with better HBV knowledge and annual health check-up adherence. When considering expanding HBV vaccination to the general adult population, we should appreciate that HBV knowledge is an independent predictor of vaccine uptake.

Prevalence of Hepatocellular Carcinoma in Hepatitis B Population within Southeast Asia: A Systematic Review and Meta-Analysis of 39,050 Participants

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is a significant complication of hepatitis B and still poses a global public health concern. This systematic review and meta-analysis provide adequate details on the prevalence of HCC in the HBV population within Southeast Asian countries.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) criteria, a thorough search for literature discussing the prevalence of HCC in the HBV population within southeast Asia was performed. Eligible studies were subjected to a meta-analysis utilising a DerSimonian and Laird approach and a random effect model. A protocol was registered with PROSPERO (CRD42023423953).

RESULT

Our study meticulously recovered 41 articles from seven countries in Southeast Asia, namely Cambodia, Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam. A total of 39,050 HBV patients and 7479 HCC cases in southeast Asia were analysed. The pooled prevalence of HCC in HBV cases within southeast Asia was 45.8% (95% CI, 34.3-57.8%, I2 = 99.51%, p < 0.001). Singapore (62.5%, CI: 42.4-79.1) had the highest pooled prevalence of HCC in the HBV population compared to Vietnam, with the lowest estimate (22.4%, CI: 9.9-44.9). There was a drop in the pooled prevalence of HCC in HBV from 2016 until now (37.6%, CI: 19.2-60.5).

CONCLUSION

The findings of this review reveal a high pooled prevalence of HCC in the HBV population and therefore stir the need for routine screening, management, and surveillance.

Survival Outcome and Prognostic Factors Among Patients With Hepatocellular Carcinoma: A Hospital-Based Study

Background

Hepatocellular carcinoma (HCC) is a leading cancer with very high incidence and mortality and low survival rate in Vietnam and worldwide. This study aimed to investigate the survival outcome and its prognostic factors among HCC patients.

Methods

This is a retrospective descriptive study on patients newly diagnosed with HCC at Hanoi Oncology Hospital, Vietnam from January 2018 to December 2020. Overall survival (OS) was calculated by the Kaplan-Meier method. Log-rank test and Cox regression were used to investigate the association among patients' OS and their diagnosis and treatment factors.

Results

A total of 674 patients were included. The median OS was 10.0 months. The survival rates at 6, 12, 24, and 36 months were 57.3%, 46.6%, 34.8%, and 29.7%, respectively. The initial performance status (PS), Child-Pugh score, and Barcelona Clinic Liver Cancer (BCLC) stage at the time of diagnosis are prognostic factors of HCC OS. A total of 451 (66.8%) patients have died, most of them (375 equally 83.1%) died at home, and only 76 (16.9%) died at hospital. Hepatocellular carcinoma patients living in the rural area more likely died at home than those living in the urban area (85.9% vs 74.8%, P = .007).

Conclusions

Hepatocellular carcinoma has a poor prognosis with low OS. Performance status, Child-Pugh score, and BCLC stage were the independent prognostic factors for the survival outcome of HCC patients. The fact that most HCC patients died at home suggested that home-based hospice care needs to be paid special attention.

Prevalence of hepatitis B virus infection in health check-up participants: a cross-sectional study at University Medical Center, Ho Chi Minh City, Vietnam

OBJECTIVES

Vietnam is one of the countries in highly endemic areas of hepatitis B virus (HBV) infection in the world. Our study aims to determine the prevalence of HBV infection among different age groups of workers who had been included for annual general health checkups.

METHODS

This cross-sectional study was conducted at the Health Screening Department, University Medical Center at Ho Chi Minh City, Vietnam, using anonymous data from employees who had health checkups from June 2017 to June 2018.

RESULTS

A total of 5727 subjects were included, with an overall HBV prevalence of 9.0%. The prevalence of HBV infection was significantly higher in men and lowest in the age groups of 18-30. In multivariable analysis, the variables that were independently associated with HBV infection were male gender (Odd ratio (OR), 2.03; 95% confidence interval (CI), 1.58-2.60; p < 0.001), older than 30 years old (age group of 31-40: OR 1.7; 95% CI, 1.33-2.18; p < 0.001; of 41-50, OR 1.82; 95% CI, 1.37-2.43; p < 0.001); high total cholesterol (OR, 0.77; 95% CI, 0.64-0.94; p = 0.011), high triglyceride (OR, 0.53; 95% CI, 0.42-0.65; p < 0.001), and having significant fibrosis (OR, 2.7; 95% CI 1.85-3,95; p < 0.001).

CONCLUSIONS

The prevalence of HBV infection among employees on health assessments is still high (9%), even in the age group under 30 (7%). Male, age group older than 30, and significant liver fibrosis were the factors related to HBV infection. High cholesterol and level triglyceride were protective factors against HBV infection.

Value of Some Scoring Systems for the Prognosis of Rebleeding and In-Hospital Mortality in Liver Cirrhosis with Acute Variceal Bleeding

Background: Upper gastrointestinal (GI) hemorrhage, caused by acute esophageal variceal bleeding, is a common complication and a leading cause of death in patients with cirrhosis. Therefore, predicting the risk in order to employ an active management to prevent rebleeding and death is crucial. Currently, there are many prognostic scoring systems that have been proposed, but research is needed to find a valid score which can be applied in clinical practice in each country and population. Aims: To compare the value of ALBI (Albumin-Bilirubin), PALBI (Platelet Albumin-Bilirubin), AIMS65, model for end-stage liver disease (MELD), and Child–Pugh scores (CPS) approaches in predicting early rebleeding and in-hospital mortality of acute variceal bleeding in patients with cirrhosis. Subjects and methods: We performed a cross-sectional descriptive study on cirrhotic patients with acute variceal bleeding who were being treated at the Department of Gastroenterology, Intensive care unit—Military Hospital 103 and the Institute for Treatment of Digestive Diseases—108 Military Central Hospital from September 2020 to May 2022. We calculated ALBI, PALBI, AIMS65, MELD, Child–Pugh values and compared them with the rates of early rebleeding and in-hospital mortality. Then, determined and compared the prognostic value through an analysis of the area under the curve (AUC). Results: 222 patients with acute esophageal variceal bleeding were eligible for inclusion in the study. The rates of rebleeding and in-hospital mortality were 9.0% and 6.8%, respectively. Regarding the prognosis of early rebleeding, the ALBI and PALBI scores have good prognostic value (AUROC 0.74; 95% CI: 0.63–0.85 and AUROC 0.7; 95% CI: 0.59–0.81; p = 0.004, respectively), while the Child–Pugh, MELD, AIMS65 scores have little prognostic value, with AUROC < 0.70. Regarding prognosis of in-hospital mortality: the ALBI, PALBI, MELD and AIMS65 all have good value in predicting in-hospital mortality, with AUROC of 0.81 (95% CI: 0.68–0.93, respectively; p < 0.001); 0.8 (95% CI: 0.69–0.91; p <0.001); 0.83 (95% CI: 0.72–0.93; p < 0.001); and 0.82 (95% CI: 0.76–0.87, p < 0.001), respectively. While Child–Pugh score only has medium prognostic value, with AUROC 0.79 (95% CI: 0.66–0.92; p < 0.05). However, there was no significant difference between these prognostic scoring systems. Conclusion: the ALBI, PALBI, MELD and AIMS65 scores all had similar good value in predicting in-hospital mortality, but with early rebleeding prognosis, only ALBI and PALBI had good value. CPS does not show prognostic value like other scores, both in predicting early rebleeding and in-hospital mortality.

Comparisons of Viral Etiology and Outcomes of Hepatocellular Carcinoma Undergoing Liver Resection between Taiwan and Vietnam

Epidemiologic data have suggested that etiologic variations of hepatocellular carcinoma (HCC) exist in different geographic areas, and might be associated with different outcomes. We compared the viral etiology, clinicopathological characteristics and surgical outcomes between 706 Taiwanese and 1704 Vietnamese patients with HCC undergoing liver resection. Vietnamese patients had a significantly higher ratio of hepatitis B virus (HBV) (p < 0.001) and a lower ratio of hepatitis C virus (HCV) (p < 0.001) and non-B non-C than Taiwanese patients. Among patients with HBV or non-B non-C, the mean age was younger in Vietnam than in Taiwan (p < 0.001, p = 0.001, respectively). The HCC patients in Vietnam had significantly higher serum alpha-fetoprotein (AFP) levels (p < 0.001), larger tumors (p < 0.001), and a higher ratio of macrovascular invasion (p < 0.001) and extrahepatic metastasis (p < 0.001), compared to those in Taiwan. Patients treated in Vietnam had a higher tumor recurrent rate (p < 0.001), but no difference in overall survival was found between both groups. In subgroup analysis, the recurrent rate of HCC was the highest in patients with dual HBV/HCV, followed by HCV or HBV, and non-B non-C (p < 0.001). In conclusion, although the viral etiology and clinicopathological characteristics of HCC differed, postoperative overall survival was comparable between patients in Taiwan and Vietnam.

Mutations in the HBV PreS/S gene related to hepatocellular carcinoma in Vietnamese chronic HBV-infected patients

Background

Chronic hepatitis B virus (CHB) infection is a major health problem and leading cause of hepatocellular carcinoma (HCC) worldwide. Several point and deletion mutations on the PreS/S gene have been intensively considered associated with HCC. This study aimed to describe the characteristics of HBV PreS/S mutations in Vietnamese CHB-infected patients and their association with HCC.

Methods

This cross-sectional study was conducted from 02/2020 to 03/2021, recruited Vietnamese CHB-infected patients with HBV-DNA >3 log₁₀-copies/mL and successful PreS/S gene sequencing. Mutations were detected by direct Sanger sequencing.

Results

247 CHB-infected patients were recruited, characterized by 68.8% males, 54.7% HBV genotype B, 57.5% HBeAg positive, 23.1% fibrosis score ≥F3 and 19.8% HCC. 61.8% amino acid replacements were detected throughout the PreS1/PreS2/S genes. The most common point-mutations included N/H51Y/T/S/Q/P (30.4%), V68T/S/I (44.9%), T/N87S/T/P (46.2%) on PreS1 gene; T125S/N/P (30.8%), I150T (42.5%) on PreS2 gene; S53L (37.7%), A184V/G (39.3%), S210K/N/R/S (39.3%) on S gene. The rates of case(s) with any point-mutation on the Major Hydrophylic Region (MHR) and the "a" determinant region were 63.6% and 39.7%, respectively. Most of S point-mutations were presented with low rates such as T47A/E/V/K (9.3%), P120S/T (8.5%), G145R (2%). On multivariable analysis, males (OR = 4.51, 95%CI 1.78–11.4, p = 0.001), age≥40 (OR = 5.5, 95%CI 2.06–14.68, p = 0.001), W4P/R/Y on PreS1 (OR = 11.56, 95%CI 1.99–67.05, p = 0.006) and 4 S point-mutations as: T47A/E/V/K (OR = 3.67, 95%CI 1.19–11.29, p = 0.023), P120S/T (OR = 3.38, 95%CI 1.09–10.49, p = 0.035), S174N (OR = 29.73, 95%CI 2.12–417.07, p = 0.012), P203R (OR = 8.45, 95%CI 1.43–50.06, p = 0.019) were associated with HCC.

Conclusions

We detected 61% amino acid changes on PreS/S regions in Vietnamese CHB patients. One point-mutation at amino acid 4 on PreS1 gene and 4 point-mutations at amino acids 47, 120, 174, and 203 on S gene were associated with HCC. Further investigations are recommended to further clarify the relationship and interaction between mutations in HBV genome and HCC progression.

Progressive Scale-up of HBV AND HCV Testing for Hepatitis Elimination in Vietnam

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Role of Baseline Albumin-Bilirubin Grade on Predict Overall Survival Among Sorafenib-Treated Patients With Hepatocellular Carcinoma in Vietnam

Introduction:

Albumin-bilirubin (ALBI) grade has been recently used in evaluation of liver function and prognosis of patients with hepatocellular carcinoma (HCC). However, in Vietnam, the utility of ALBI grade in clinical setting has not been adequately investigated.

Methods:

This is a retrospective study of 110 patients with HCC treated with sorafenib from January 2010 to November 2018 at 2 tertiary hospitals in Vietnam. Prognostic value of ALBI grade was evaluated by Kaplan-Meier survival analysis and Cox proportional regression model.

Results:

Results showed that the majority of ALBI grade 1 were Child-Pugh level A (97.5%); ALBI grade 2 was seen in all Child-Pugh score groups of 5, 6, 7, ≥8, whereas ALBI grade 3 was mostly reported in Child-Pugh score ≥8 group (83.3%). Compared with ALBI grade 3, ALBI grade 1 reduced 66.4% risk of death (hazards ratio [HR] = 0.336, 95% confidence interval [CI]: 0.115-0.981; P = .046). Compared with ALBI grade 3, ALBI grade 2 reduced 67.3% risk of death (HR = 0.327, 95% CI: 0.122-0.875; P = .026). Albumin-bilirubin grade was an independent predictor of survival outcome.

Conclusion:

Baseline ALBI grade is a simple and objective approach in assessing liver functions of patients with HCC. Baseline ALBI grade is an independent predictor of survival in patients treated with sorafenib.

A Rare Colonic Metastasis Case from Hepatocellular Carcinoma

BACKGROUND

Hepatocellularcarcinoma (HCC) metastasis include intrahepatic and extrahepatic metastasis. Similar to intrahepatic metastasis, extrahepatic metastases are not unusual in cases with HCC. However, colonic metastasis is infrequent.

CASE REPORT

We describe a clinical case, he was diagnosed with HCC a year ago, treated with TACE (transarterialchemoembolisation), re-examined with abdominal pain and defecation disorder. The tests such as CT scan, colorectal endoscopy, fine needle aspiration (FNA) revealed secondary metastatic lesion of HCC in sigmoid colon. This is the first gastrointestinal (GI) tract metastatic we have encountered.

CONCLUSION

HCC metastases of the colon are rare, especially cases of hematogenous spread. The prognosis of these patients is often very critical. Indications for surgical removal of the lesion may be used if the general situation of patient is acceptable.

Phase I Clinical Trial Using Autologous Ex Vivo Expanded NK Cells and Cytotoxic T Lymphocytes for Cancer Treatment in Vietnam

(1) Background: Immune cell therapy recently attracted enormous attention among scientists as a cancer treatment, but, so far, it has been poorly studied and applied in Vietnam. The aim of this study was to assess the safety of autologous immune cell therapy for treating lung, liver, and colon cancers-three prevalent cancers in Vietnam. (2) Method: This was an open-label, single-group clinical trial that included 10 patients with confirmed diagnosis of colon, liver, or lung cancer, conducted between March 2016 and December 2017. (3) Results: After 20-21 days of culture, the average number of cytotoxic T lymphocytes (CTLs) increased 488.5-fold and the average cell viability was 96.3%. The average number of natural killer cells (NKs) increased 542.5-fold, with an average viability of 95%. Most patients exhibited improved quality of life, with the majority of patients presenting a score of 1 to 2 in the Eastern Cooperative Oncology Group (ECOG) performance status (ECOG/PS) scale, a decrease in symptoms on fatigue scales, and an increase in the mean survival time to 18.7 months at the end of the study. (4) Conclusion: This method of immune cell expansion met the requirements for clinical applications in cancer treatment and demonstrated the safety of this therapy for the cancer patients in Vietnam.

PIVKA-II as a Potential New Biomarker for Hepatocellular Carcinoma - A Pilot Study

AIM

The aim of this study was to evaluate the clinical contribution of protein induced by vitamin K absence (PIVKA-II) for hepatocellular carcinoma (HCC) diagnostics and compare it with alpha-foetoprotein (AFP), a routinely used tumour marker.

MATERIALS AND METHODS

A total of 332 participants were enrolled in this study: 64 with HCC, 48 with liver metastases of colorectal cancer origin, 42 with liver cirrhosis and 178 healthy individuals. Serum levels of PIVKA-II were measured using the chemiluminescent assay of the Architect 1000i System (Abbott, USA) and AFP levels using the chemiluminescent assay by DxI 800 (Beckman Coulter, USA).

RESULTS

PIVKA-II achieved better clinical sensitivity than AFP and the difference in this sensitivity was statistically significant. PIVKA-II achieved the best sensitivity (96.9%) in distinguishing between the HCC and control groups with the proposed cut-off value of 60 mAU/ml.

CONCLUSION

Our recommendation is for addition of PIVKA-II to the routine panel of HCC tumour markers.