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\begin{document}

\title{Clinical Profile, Risk Factors, and Treatment of Hepatocellular
Carcinoma in Nepal: A Single Centre Experience}



\author[1]{Arun  Gnawali}%
\author[1]{Rahul  Pathak}%
\author[1]{Dinesh Koirala}%
\author[1]{Rajesh Pandey}%
\author[1]{Rabin  Hamal}%
\author[1]{Anurag Jha}%
\author[1]{Brindeswari Kafle Bhandari}%
\author[1]{Siddinath Gyawali}%
\affil[1]{Tribhuvan University Teaching Hospital}%


\vspace{-1em}



  
  \date{May 21, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Background Hepatocellular carcinoma (HCC) is the most common primary
liver cancer. Liver cancer is one of the commonest cancers worldwide in
terms of incidence and mortality. Viral hepatitis, alcohol abuse, and
autoimmune hepatitis are the common causes of HCC. Usually patients
present at advanced stages where curative treatment is no longer
possible. This study aims to analyze the demographic, clinical, and
radiological profiles and treatment patterns of HCC patients. Methods We
studied patients with HCC from March 2020 to August 2022 and analyzed
their risk factors, clinical characteristics, and treatment modalities.
Patients with at least one clinical, radiological, or biochemical
evidence of HCC were considered for the study. Data were collected using
predetermined proformas. Results Our study included 54 patients with a
mean age of 57.17 years, and male: female ratio of 5:1. Of them, 68.52\%
consumed alcohol and 74.07\% smoked cigarettes. At the time of
diagnosis, 88.89\% of them were symptomatic, weight loss (64.81\%) being
the most common symptom. The majority of the participants belonged to
Barcelona Clinic Liver Cancer (BCLC) terminal stage (38.89\%) and had
more than three liver lesions (35.19\%) involving the right lobe
(55.56\%). Only four patients underwent curative surgical resection. As
most were in the terminal stage (BCLC D), supportive care was provided.
Conclusion Alcohol-related liver cirrhosis is the most common cause of
HCC in Nepal. Despite the significant progress in diagnostic methods,
most of the patients are diagnosed at advanced and terminal stages.
These patients are unsuitable for curative treatment and are treated
with supportive methods. Keywords Autoimmune hepatitis, hepatitis,
hepatocellular carcinoma, treatment.%
\end{abstract}%



\sloppy


\textbf{Clinical Profile, Risk Factors, and Treatment of Hepatocellular
Carcinoma in Nepal: A Single Centre Experience}

\textbf{AUTHORS}

Arun Gnawali\textsuperscript{1}(arungnawali969@gmail.com, ORCID ID:
https://orcid.org/0000-0003-2375-9960

Rahul Pathak\textsuperscript{1}(dr.rahuliom@gmail.com, ORCID ID:
https://orcid.org/0000-0002-9748-2717)

Dinesh Koirala\textsuperscript{1}(dkoirala045@gmail.com, ORCID ID:
https://orcid.org/0000-0002-5556-2786)

Rajesh Pandey\textsuperscript{1}(rajeshpandeya@gmail.com, ORCID ID:
https://orcid.org/0000-0001-6065-3108)

Rabin Hamal\textsuperscript{1}(rabham@gmail.com, ORCID ID:
https://orcid.org/0000-0002-7782-1865)

Anurag Jha\textsuperscript{1}(drjhanurag@gmail.com, ORCID ID:
https://orcid.org/0000-0001-8252-8084)

Brindeswari Kafle Bhandari\textsuperscript{1}(drbindi20@gmail.com, ORCID
ID: https://orcid.org/0009-0006-9341-8773)

Siddinath Gyawali\textsuperscript{1} (sirdhar.gyawali@gmail.com, ORCID
ID: https://orcid.org/0000-0003-0597-0711)

\textsuperscript{1}Department of Gastroenterology, Tribhuvan University
Teaching Hospital, Institute of Medicine, Kathmandu, Nepal.

\textbf{CORRESPONDING AUTHOR}

Arun Gnawali

Email ID: arungnawali969@gmail.com

Department of Gastroenterology, Tribhuvan University Teaching Hospital,
Institute of Medicine, Kathmandu, Nepal.

\textbf{ACKNOWLEDGEMENTS:} None

\textbf{ETHICAL APPROVAL STATEMENT}

The study was approved by the Institutional Review Committee of the
Institute of Medicine (reference number: 132/ (6-11)
E\textsuperscript{2}/076/077), and informed consent was taken from each
patients.

\textbf{ABSTRACT}

\textbf{Background}

Hepatocellular carcinoma (HCC) is the most common primary liver cancer.
Liver cancer is one of the commonest cancers worldwide in terms of
incidence and mortality. Viral hepatitis, alcohol abuse, and autoimmune
hepatitis are the common causes of HCC. Usually patients present at
advanced stages where curative treatment is no longer possible. This
study aims to analyze the demographic, clinical, and radiological
profile and treatment patterns of HCC patients.

\textbf{Methods}

We studied patients with HCC from March 2020 to August 2022 and analyzed
their risk factors, clinical characteristics, and treatment modalities.
Patients with at least one clinical, radiological, or biochemical
evidence of HCC were considered for the study. Data were collected using
predetermined proformas.

\textbf{Results}

Our study included 54 patients with a mean age of 57.17 years, and male:
female ratio of 5:1. Of them, 68.52\% consumed alcohol and 74.07\%
smoked cigarettes. At the time of diagnosis, 88.89\% of them were
symptomatic, weight loss (64.81\%) being the most common symptom. The
majority of the participants belonged to Barcelona Clinic Liver Cancer
(BCLC) terminal stage (38.89\%) and had more than three liver lesions
(35.19\%) involving the right lobe (55.56\%). Only four patients
underwent curative surgical resection. As most were in the terminal
stage (BCLC D), supportive care was provided.

\textbf{Conclusion}

Alcohol-related liver cirrhosis is the most common cause of HCC in
Nepal. Despite the significant progress in diagnostic methods, most of
the patients are diagnosed at advanced and terminal stages. These
patients are unsuitable for curative treatment and are treated with
supportive methods.

\textbf{Keywords}

Autoimmune hepatitis, hepatitis, hepatocellular carcinoma, treatment.

\textbf{INTRODUCTION}

Liver cancer is one of the commonest cancers worldwide which occupies
fifth and seventh ranks in terms of incidence among males and females
respectively, and fourth position in overall
mortality.\textsuperscript{1} The higher age-standardized rates (ASR) of
incidence of liver cancer i.e. 22.2 and 7.2 per 100,000 population among
males and females respectively in South East Asia suggest that this
tumor is more prevalent in the developing world where the prevalence of
viral hepatitis B and hepatitis C is higher. As per the same report, the
estimated mortality of liver cancer in this region is 21.4 and 6.8 per
100,000 for males and females respectively.\textsuperscript{2} According
to the National Cancer Registry of Nepal (2013), the incidence of liver
cancer in Nepal in men and women is 0.8 and 0.9 per 100,000 population
respectively. However, the mortality rates of cancer are not recorded in
the registry.\textsuperscript{3}

Hepatocellular carcinoma (HCC) is the most common primary liver cancer,
the other less common types being intrahepatic cholangiocarcinoma (ICC),
angiosarcoma, hemangiosarcoma, and hepatoblastoma in the descending
order of their occurrence.\textsuperscript{4, 5}

Liver cirrhosis is the most common cause of HCC accounting for 80\% of
cases.\textsuperscript{6} The commonest risk factors for HCC are viral
hepatitis (hepatitis B and hepatitis C infection), excessive alcohol
use, occupational exposure, nonalcoholic fatty liver disease (NAFLD),
and autoimmune hepatitis (AIH).\textsuperscript{6} These factors lead to
liver cirrhosis which is also considered as a premalignant state. The
cirrhotic cells are more likely to undergo dysplasia and may lead to HCC
development.\textsuperscript{6} The patients with hepatic cirrhosis and
those with suspected HCC are investigated with noninvasive modalities
like multiphasic contrast-enhanced computed tomography (CECT),
contrast-enhanced magnetic resonance imaging (CE-MRI) of the abdomen to
verify the presence of HCC (diagnosis) and to determine its extent
(radiological staging).\textsuperscript{7}

The Barcelona Clinic Liver Cancer (BCLC) algorithm is the most widely
used staging system. Patients with a single liver tumor or as many as
three nodules of less than 3 cm diameter are classified as having very
early-stage (BCLC stage 0) or early-stage (BCLC stage A) cancer. These
patients benefit from curative treatment modalities like resection,
transplantation, or ablation. Those with a greater tumor burden,
confined to the liver, but are free of symptoms are considered to have
intermediate-stage (BCLC stage B) cancer. If their liver function is
intact, they can be benefitted from chemoembolization. Those with
symptoms of HCC and/or vascular invasion and/or extrahepatic cancer are
considered to have advanced-stage (BCLC stage C) and terminal-stage
(BCLC stage D) cancer. These patients could benefit from treatment with
the kinase inhibitor, sorafenib.\textsuperscript{8}

Though the cancer registry began in Nepal in 2003, the registry is not
comprehensive, and there are very limited studies conducted on liver
cancers in Nepal.\textsuperscript{9} In this single center-based study,
we have analyzed clinical, etiological, and radiological data and
treatment patterns of patients with liver cancer visiting the outpatient
department (OPD) or admitted to the Department of Gastroenterology in
Tribhuvan University Teaching Hospital (TUTH).

\textbf{METHODS}

This is a descriptive cross-sectional study. Fifty-four patients with
HCC who either visited the OPD or were admitted to the TUTH under the
Department of Gastroenterology from March 2020 to August 2022 were
considered for the study. These patients had at least one clinical,
radiological, or biochemical evidence of HCC. We analyzed the risk
factors, clinical characteristics, and treatment modalities in patients
with HCC. The diagnosis of HCC was made by detailed clinical
examination, imaging modality (dynamic CT scan or MRI of the abdomen)
which show early arterial enhancement and venous washout of the lesion,
or with the biopsy of the lesion whenever necessary. Predetermined
proforma was used as a tool for data collection. The study was approved
by the Institutional Review Committee of the Institute of Medicine
(reference number: 132/ (6-11) E\textsuperscript{2}/076/077).

\textbf{Statistical Analysis}

The data obtained from the above study were tabulated in Microsoft Excel
2016. The statistical analysis was done using SPSS (Statistical Package
for the Social Sciences) version 21. Results on continuous variables
were expressed as mean \selectlanguage{ngerman}± standard deviation (SD) and results on
categorical variables were expressed in number (\%).

\textbf{RESULTS}

We enrolled and analyzed 54 patients who had hepatocellular carcinoma.
The youngest patient in our study was 28 years old, the oldest was of
81years, and the mean age was 57.17 years. Of them, 46 (85.18\%) were
male and 8 (14.82\%) were female. The majority of the patients in the
study followed Hinduism (75.93\%). Of the total participants, 37
(68.52\%) consumed alcohol and a majority of them were smokers
(74.07\%). Comorbidity in the form of diabetes mellitus was present in
five patients (9.26\%), hypertension in six patients (14.81\%), and both
diabetes and hypertension were present in eight patients (11.11\%)
(Table 1).

We also analyzed all the patients to determine the possible etiologies
of HCC. The study depicted that, alcohol abuse was the commonest cause
of HCC (38.89\%) followed by chronic viral hepatitis B (CHB) infection
(11.11\%). In addition, 12 patients (22.22\%) had a history of both
significant alcohol consumption as well as CHB infection (Table 2).

At the time of diagnosis, most of the patients were symptomatic
(88.89\%). The commonest presenting symptoms were weight loss (64.81\%),
abdominal distension (61.11\%), anorexia (61.11\%), and abdominal pain
(50.0\%). Ascites was present in more than half of the patients
(59.26\%) and hepatic encephalopathy was found in only four patients
(7.41\%) (Table 3).

All patients underwent imaging by either triple phase CT scan or an MRI
of the abdomen. The HCC most commonly involved the right lobe of liver
(55.56\%) followed by the bilobar involvement (29.63\%). The left lobe
was involved in eight patients (14.78\%). Multicentric HCC with more
than three lesions was the most common radiological pattern (35.19\%)
followed by the single lesion (27.78\%). Vascular involvement of the
porto-splenic axis was seen in nearly half of the patients (44.44\%).
Extrahepatic spread of the tumor was seen in eight patients (14.81\%).
Four patients (7.41\%) had regional periportal lymph node involvement,
two (3.70\%) had metastasis to the lung, and the remaining two (3.70\%)
had metastasis to the peritoneum. On detailed evaluation, 42 patients
(77.78\%) were found to have underlying liver cirrhosis. The majority of
cirrhotic patients had already progressed to the decompensated stage
(80.95\%).

Child-Turcotte-Pugh (CTP) status was calculated in all patients. The
analysis depicted that 23 (42.59\%) patients had CTP A, 14 (25.93\%) had
CTP B, and 17 (31.48\%) had CTP C. Functional status was assessed by
using Eastern Cooperative Oncology Group (ECOG) performance status, and
most common performance status was ECOG 0 (37.04\%) followed by ECOG 2
(20.37\%) and ECOG 3 (20.37\%). Based on tumor characteristics, CTP
score, and ECOG performance status, BCLC (Barcelona Clinic Liver Cancer
(BCLC) staging was done. The analysis showed that the majority of the
participants belonged to the terminal stage (BCLC category D) (38.89\%)
followed by the advanced stage (BCLC category C) (35.19\%). None of our
patients was detected in the very early stage (BCLC category 0). (Table
4)

The evaluation of laboratory parameters among the participants
demonstrated that the serum alpha-fetoprotein was elevated in 44
patients (81.48\%) with a mean value of 525±37 ng/ml. The majority of
the patients were anemic with a mean value of hemoglobin of 10.9±2.7
g/dl. The mean values of serum sodium level, AST, and ALT were within
normal limits, however, mean serum alkaline phosphatase (ALP) was raised
as shown in Table 5. The mean values of CTP score, Model for End-Stage
Liver Disease (MELD) score, and MELD-Na score were also calculated.
(Table 5)

Most of the patients (92.59\%) underwent non-surgical treatment and only
four patients underwent surgical treatment i.e., tumor resection. Among
non-surgical treatment modalities, only 2 patients underwent therapy
with curative intent in the form of microwave ablation. As most of our
patients were in the terminal stage (BCLC D), they were provided with
the best supportive care. Some patients received transarterial
chemoembolization (TACE) (50.0\%) and chemotherapy with sorafenib
(31.48\%) as palliative therapeutic measures. (Table 6)

\textbf{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{10,12} However, a similar study conducted by Egypt
showed HBV infection in only 22.4\% of total cases of
HCC.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.\textsuperscript{11} However other similar studies found PVT in
less than 20\% of total cases only.\textsuperscript{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.\textsuperscript{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.\textsuperscript{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.

\textbf{CONCLUSION}

In summary, our study depicted that, older age, male gender, excess
alcohol intake, viral hepatitis, and liver cirrhosis were the common
risk factors for liver cancer in Nepal. Since most of the patients are
asymptomatic in the initial stage of cancer, it is already late when
they become symptomatic and present to us when curative treatment is no
longer possible. Being a single-center study, the findings are not
generalizable to all the Nepalese population. Therefore, we suggest a
multicenter study to draw a clearer picture of the prevalence, risk
factors, clinical presentation, and treatment modalities of HCC in
Nepal.

\textbf{ABBREVIATIONS}

AIH: Autoimmune Hepatitis

ASR: Age-standardized Rates

Barcelona Clinic Liver Cancer (BCLC)

CECT: Contrast-Enhanced Computed Tomography

CE-MRI: Contrast-Enhanced Magnetic Resonance Imaging

CHB: Chronic Viral Hepatitis B

CTP: Child-Turcotte-Pugh

ECOG: Eastern Cooperative Oncology Group

g/dl: Gram per deciliter

g/l: Gram per liter

HCC: Hepatocellular Carcinoma

ICC: Intrahepatic Cholangiocarcinoma

IU/L: International Unit per Liter

MELD: Model for End-Stage Liver Disease

MELD-Na: Model for End-Stage Liver Disease Sodium

meq/l: Milliequivalent per liter

NAFLD: Nonalcoholic Fatty Liver Disease

ng/ml: Nanogram per milliliter

OPD: Outpatient Department

\textbf{AUTHOR CONTRIBUTIONS}

\textbf{Arun Gnawali:} Conceptualization, data collection, data
analysis, manuscript writing, and editing the draft

\textbf{Rahul Pathak:} Conceptualization, data analysis, supervision,
and editing the draft

\textbf{Dinesh Koirala:} Data analysis, supervision, and editing the
draft

\textbf{Rajesh Pandey:} Data analysis, and editing the draft

\textbf{Rabin Hamal:} Data collection, data analysis, and editing the
draft

\textbf{Anurag Jha:} Data collection, data analysis, and editing the
draft

\textbf{Brindeswari Kafle Bhandari:} Data collection, data analysis, and
editing the draft

\textbf{Siddinath Gyawali:} Manuscript writing, data analysis, and
editing the draft

\textbf{FUNDING INFORMATION:} None

\textbf{CONFLICT OF INTEREST}

The Authors declare that there is no conflict of interest.

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\textbf{Table 1.} Demographic profile of the patients (n = 54)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Patient characteristics} & \textbf{Patient characteristics} &
\textbf{Number (\%)}\tabularnewline
\midrule
\endhead
Age wise distribution (in years) & [?]40 & 6 (11.11)\tabularnewline
& 40-49 & 8 (14.81)\tabularnewline
& 50-59 & 14 (25.92)\tabularnewline
& 60-69 & 13 (24.07)\tabularnewline
& [?]70 & 13 (24.07)\tabularnewline
Gender & Male & 46 (85.18)\tabularnewline
& Female & 8 (14.82)\tabularnewline
Religion & Hindu & 41 (75.93)\tabularnewline
& Buddhist & 13 (24.07)\tabularnewline
HCC diagnosis & Symptomatic & 48 (88.89)\tabularnewline
& Incidental & 6 (11.11)\tabularnewline
Co-morbidities & HTN & 5 (9.26)\tabularnewline
& DM & 8 (14.81)\tabularnewline
& DM+HTN & 6 (11.11)\tabularnewline
Alcohol use & Alcohol use & 37 (68.52)\tabularnewline
Smoking & Smoking & 40 (74.07)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 2.} Etiology of HCC (n = 54)\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Etiology} & \textbf{Number (\%)}\tabularnewline
\midrule
\endhead
Alcohol & 21 (38.89)\tabularnewline
HBV & 6 (11.11)\tabularnewline
NAFLD & 2 (37.03)\tabularnewline
Alcohol + HBV & 12 (22.22)\tabularnewline
Alcohol + HCV & 4 (7.41)\tabularnewline
Cryptogenic & 6 (11.11)\tabularnewline
Hereditary hemochromatosis & 3 (5.56)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 3.} Clinical features of patients with HCC (n = 54)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Clinical features} & \textbf{Number (\%)} & \textbf{Number (\%)}
& \textbf{Number (\%)}\tabularnewline
\midrule
\endhead
Pain abdomen & 27 (50.0) & 27 (50.0) & 27 (50.0)\tabularnewline
Abdominal distention & 33 (61.11) & 33 (61.11) & 33
(61.11)\tabularnewline
Anorexia & 33 (61.11) & 33 (61.11) & 33 (61.11)\tabularnewline
Weight loss & 35 (64.81) & 35 (64.81) & 35 (64.81)\tabularnewline
Jaundice & 8 (14.81) & 8 (14.81) & 8 (14.81)\tabularnewline
UGI bleed & 6 (11.11) & 6 (11.11) & 6 (11.11)\tabularnewline
Altered sensorium & 2 (37.04) & 2 (37.04) & 2 (37.04)\tabularnewline
Ascites & 32 (59.26) & Grade I & 5 (15.63)\tabularnewline
& & Grade II & 4 (12.50)\tabularnewline
& & Grade III & 23 (71.88)\tabularnewline
Hepatic encephalopathy & 4 (7.41) & 4 (7.41) & 4 (7.41)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 4.} Malignancy characteristics of HCC (n = 54)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Malignancy characteristics} & \textbf{Malignancy
characteristics} & \textbf{Malignancy characteristics} & \textbf{Number
(\%)}\tabularnewline
\midrule
\endhead
No. of lesion & 1 & 1 & 15 (27.78)\tabularnewline
& 2 & 2 & 8 (14.81)\tabularnewline
& 3 & 3 & 12 (22.22)\tabularnewline
& \textgreater{}3 & \textgreater{}3 & 19 (35.19)\tabularnewline
Lobe of liver & Right & Right & 30 (55.56)\tabularnewline
& Left & Left & 8 (14.81)\tabularnewline
& Both & Both & 16 (29.63)\tabularnewline
CTP status & A & A & 23 (42.59)\tabularnewline
& B & B & 14 (25.93)\tabularnewline
& C & C & 17 (31.48)\tabularnewline
ECOG performance status & 0 & 0 & 20 (37.04)\tabularnewline
& 1 & 1 & 8 (14.81)\tabularnewline
& 2 & 2 & 11 (20.37)\tabularnewline
& 3 & 3 & 11 (20.37)\tabularnewline
& 4 & 4 & 4 (7.41)\tabularnewline
BCLC Staging & 0 & 0 & 0\tabularnewline
& A & A & 8 (14.81)\tabularnewline
& B & B & 6 (11.11)\tabularnewline
& C & C & 19 (35.19)\tabularnewline
& D & D & 21 (38.89)\tabularnewline
Distant metastasis & Yes & Yes & 8 (14.81)\tabularnewline
& No & No & 46 (85.19)\tabularnewline
Portal vein thrombosis & Yes & Yes & 24 (44.44)\tabularnewline
& No & No & 30 (55.56)\tabularnewline
AKI & Yes & Yes & 8 (18.81)\tabularnewline
& No & No & 46 (85.19)\tabularnewline
AFP elevated & Yes & Yes & 44 (81.48)\tabularnewline
& No & No & 10 (18.52)\tabularnewline
Liver status & Cirrhotic & Decompensated & 34 (62.97)\tabularnewline
& & Compensated & 8 (14.81)\tabularnewline
& Non-cirrhotic & Non-cirrhotic & 12 (22.22)\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 5.} Laboratory parameters of patients with HCC (n = 54)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Parameters} & \textbf{Mean value} & \textbf{Normal references
used}\tabularnewline
\midrule
\endhead
Hemoglobin (g/dl) & 10.9\selectlanguage{ngerman}±2.7 & 12.5-15 gm\%\tabularnewline
Total bilirubin (micromole/l) & 60.6\selectlanguage{ngerman}±13 & 5-21 \selectlanguage{greek}µ\selectlanguage{english}Mol/L\tabularnewline
Serum albumin (g/l) & 32.2\selectlanguage{ngerman}±4 & 34 to 54 g/L\tabularnewline
Sodium (meq/l) & 135\selectlanguage{ngerman}±4 & 135-146 meq/L\tabularnewline
AST (IU/L) & 114\selectlanguage{ngerman}±20 & 0-35 U/L\tabularnewline
ALT (IU/L) & 52\selectlanguage{ngerman}±11 & 0-35 U/L\tabularnewline
ALP (IU/L) & 525\selectlanguage{ngerman}±44 & 30-120 U/L\tabularnewline
AFP level (ng/ml) & 525\selectlanguage{ngerman}±37 & 0 ng/mL to 40 ng/mL\tabularnewline
CTP score & 7.7\selectlanguage{ngerman}±1.6 & -\tabularnewline
MELD score & 12.78\selectlanguage{ngerman}±3 & -\tabularnewline
MELD-Na score & 14.19\selectlanguage{ngerman}±4.2 & -\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 6.} Management modality of the patients with HCC. (n = 54)\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\textbf{Management Modality} & \textbf{Management Modality} &
\textbf{Management Modality} & \textbf{Number (\%)}\tabularnewline
\midrule
\endhead
Surgical & Surgical & Surgical & 4 (7.41)\tabularnewline
Non-surgical & & & 50 (92.59)\tabularnewline
& Potentially curative (micro-ablation) & Potentially curative
(micro-ablation) & 2 (3.70)\tabularnewline
& Palliative & TACE & 10 (18.52)\tabularnewline
& & Sorafenib & 17 (31.48)\tabularnewline
& Best supportive & Best supportive & 21 (38.89)\tabularnewline
\bottomrule
\end{longtable}

\selectlanguage{english}
\FloatBarrier
\end{document}

