Guidelines for the management of hepatocellular carcinoma in Sri Lanka-consensus statement

Sri Lanka has a rising population of patients with chronic liver cell disease. Incidence of metabolic liver disease in the country is one of the highest in the world [1]. Over the last 5 years, the number of HCC cases reported has steadily increased. HCC has become a disease of discussion due to rise in the incidence, recent accessibility of all treatment options, and availability of trained clinicians in managing HCC [2].


SLHPBA Guidelines for the management of hepatocellular carcinoma in Sri Lanka -consensus statement 1. Prevention of HCC in Sri Lanka a. Hepatitis B vaccination
Even though incidence of Hepatitis B is extremely low, it is recommended to continue hepatitis B vaccination which is currently included in the national immunization program.Ÿ Frequency of screening is to be decided by the clinician as firm data is not yet available.

c. Hepatitis screening in Sri Lankan patients.
Ÿ Considering the extremely low incidence, screening for hepatitis B and C is likely to yield negative results.Nonavailability or delay in these reports should not delay the management of HCC.

d.Place of alpha feto protein (AFP)
Ÿ Alpha feto protein has limited value in screening for HCC.Ÿ Alpha feto protein is useful as an adjunct for imaging.Ÿ Alpha feto protein is an important test in prognostication of HCC.

Diagnosis of HCC a. Cirrhotic patients
Key words: Hepatocellular carcinoma; carcinoma hepatocellular; therapy; carcinoma hepatocellular; epidemiology Sri Lanka has a rising population of patients with chronic liver cell disease.Incidence of metabolic liver disease in the country is one of the highest in the world [1].Over the last 5 years, the number of HCC cases reported has steadily increased.HCC has become a disease of discussion due to rise in the incidence, recent accessibility of all treatment options, and availability of trained clinicians in managing HCC [2].
There are regional guidelines published based on data from Europe, North America and East Asia.Infective hepatitis is rare in Sri Lankan patients.Apart from having a unique etiology, many practical difficulties are faced when directly applying these guidelines in the context of the local setting.In this background, Sri Lanka Hepato Pancreatico Biliary Association (SLHPBA) organized a consensus meeting to modify the already established clinical guidelines in a manner applicable to Sri Lanka.
In formulating the guidelines, feasibility and the local pattern of disease were considered.Overseas experts representing North America, Europe and India participated in the discussions.As local representatives, members representing Society of Gastroenterology, Radiology, Oncology, Pathology and General Surgery, participated in the discussions.Already published European association of study of liver disease guidelines [3], Asia Pacific clinical practice guidelines 2017 [4] and American association of study of liver disease guidelines 2016 [5], were used as a baseline platform.
Each point was taken up, discussed and debated prior to an agreement. The

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It is recommended to use a specially prepared request form within institutions indicating a clear clinical history.b.Screening of high risk NASH groups.i.Diabetics who are older than 40 years with elevated AST/ALT may be subjected to ultrasound scan screening.

Any lesion with AFP over 400 ng/ml is diagnostic of HCC. vi. PET scan has only a limited role in diagnosing HCC. vii.Patients with portal vein thrombosis may not demonstrate a typical enhancement pattern in CT or MRI 4. Treatment of HCC is best decided in a multi disciplin- ary meeting with a HPB surgeon, Hepatologist, Radi- ologist and an Oncologist
Can be offered to patients with unresectable disease.2.Has no place as an adjuvant treatment for surgery or ablation 3.Can be used for TACE refractory tumours.c.Cirrhotic -Child-Pugh B and C i.Only minor resections are considered in Child -Pugh B stable patients.ii.There is no place for surgery in Child -Pugh C iii. Ablation should be considered in Child -Pugh B patients iv.Patients with Child -Pugh C are candidates for palliative care.v.There is no place for Sorafenib in Child -Pugh C cases.