Towards an Egyptian guideline from screening to treatment of hepatocellular carcinoma [part I]

These recommendations provide a data-supported and based-evidenced approach to the screening, diagnosis, staging and treatment of Egyptian patients with hepatocellular carcinoma [HCC] in which we tried to construct an Egyptian algorithm for our Egyptian HCC patients in terms of type and timing of surveillance, readily available diagnostic tools that suit our means and the proper and efficient timely treatment that suits our resources. They are based on the experience of the authors in the specified topic and the AASLD Policy on the Development and Use of Practice Guidelines. These recommendations suggest preferred approaches to screening [for early detection of cases with hepatic nodule and/or elevated AFP], diagnosis [for accurate diagnosis of HCC cases], staging [for detection of specific category of treatment according the patient's general condition] and treatment [selection of the most suitable treatment option for the patient after his proper evaluation]. In an attempt to characterize the quality of evidence supported recommendations, the Egyptian Guidelines requires a category to be assigned and reported with each recommendation [Table I]

Towards an Egyptian guideline from screening to treatment of hepatocelhilar carcinoma [part II]

These recommendations provide a data-supported and evidence based approach to the screening, diagnosis, staging and treatment of Egyptian patients with hepatocellular carcinoma [HCC] in which we tried to construct an Egyptian algorithm for our Egyptian HCC patients in terms of type and timing of surveillance, readily available diagnostic tools that suits our means and the proper and efficient timely treatment that suits our resources. They are based on the experience of the authors in the specified topic and the AASLD Policy on the Development and Use of Practice Guidelines. These recommendations suggest preferred approaches to screening [for early detection of cases with hepatic nodule and/or elevated AFP], diagnosis [for accurate diagnosis of HCC cases], staging [for detection of specific category of treatment according the patient's general condition] and treatment [selection of the most suitable treatment option for the patient after his proper evaluation]. In an attempt to characterize the quality of evidence supported recommendations, the Egyptian Guidelines requires a category to be assigned and reported with each recommendation [Table 1]

Assessment of a guideline for management of hepatocellular carcinoma [HCC] in Egyptian patients

HCC is the commonest liver malignancy all over the world including in Egypt. Many classification system for management of HCC have been proposed but none of them is implemented worldwide. In this work we propose a guideline for management of HCC which is suitable for the Egyptian patient. The suggested guideline of management includes assessment of four areas: The general clinical status of the patient, the liver status, the tumor status and options of therapy which are suitable for Egyptian circumstances. In one center, this design was prospectively applied on 79 patients who presented with HCC. The HCC patients showed that: Two [2.86%] had non-cirrhotic liver parenchyma, while all the rest had cirrhosis: 7 [10.0%] early stage or Child's A [one early and 6 late Child's A], 28 [40.0%] intermediate stage [Child's B] and 33 [47.14%] terminal end stage [Child's C]. Therapy was applied according to the suggested guideline as follows: surgical resection for four patients [5.71%], radio frequency ablation [RFA] for 6 [8.57%], percutaneous ethanol injection [PEI] for 39 [55.71%], selective arterial chemoembolization for 2 [2.86%], chemotherapy for 6 [5.57%] and symptomatic therapy for 13 [18.75%] patients. After two years of follow up: Fourty four [62.9%] were still living, 20 [28.6%] died while 6 [8.6%] were missed to follow up. Recurrence of HCC was found in 21 [30.0%] cases. The liver status progressed from Child's A to B in four cases out of 7 [57.1%] and from Child's B to C in 24 cases out of 28 [85.71%] within one year. The prognosis of the disease depended on many factors on top of which was the liver functional reserve. Most Egyptian patients with HCC present in a late stage of cirrhosis thus with a bad prognosis as predicted from their clinical status, the liver condition and the tumor status. The progress of the underlying liver disease is more rapid when HCC appears. PEI is a good option of therapy. The predictive factors of good prognosis and improvement in this study were HBV infection and the Child's class. Although the mortality rate was still high [28.5%], but the cost of therapy was reduced due to application of the suggested guideline system. This guideline is simple, easy to apply, covers most HCC presentations, is flexible and may be changed [updated] according to progress in technology, resources of therapeutics, skills of the operators and the patient's presentation. Thus other Egyptian centers can apply this guideline in management of HCC, reevaluating and updating it