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.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.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.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.4, 5
Liver cirrhosis is the most common cause of HCC accounting for 80% of cases.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).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.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).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.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.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).