HEPATOCELLULAR CARCINOMA (HCC) at Liver Tumor Department – Cho Ray Hospital 2010 - 2016 NGUYEN DINH SONG HUY, MD Vice Director of Cancer Center Head of Liver Tumor Department Cho Ray Hospital

2016 : HCC is the 5th (male) and the 9th (female) most common cancer worldwide Nam Nữ Cancer incidence worldwide (Globocan 2016, IARC, WHO)

GLOBOCAN 2012 (IARC) Section of Cancer Surveillance HCC in Vietnam GLOBOCAN 2012 (IARC) Section of Cancer Surveillance

Study purposes Number of new HCC patients per years Number of new HCC patients already in far advanced stage per years Relationship with hepatitis virus infection Value of AFP in diagnosis of HCC

Materials & Methods Inclusive criteria : All adult patients, ≥ 15 yo. Diagnosed of HCC at Liver Tumor Department Cho Ray hospital 2010-2016 according to Vietnam Guideline for HCC 2012 Methods : Retro-observational study

6 * Associated diseases with high risk in operation Child B Easy to approach Associated diseases * Child C Child A,B Any size PV thrombosis, N1, M1 PST 1-2 Child A/B PST >2 End stage ≤ 3 tumor, ≤ 3cm 1 tumor ≤ 5cm Resection RFA Transplantation TACE Sorafenib Multifocal tumors PST 0-2 Child A/B PST 0-1 Resectable No metastasis, no PV hypertension Unresectable HEPATOCELLULAR CARCINOMA Liver biopsy Increasing AFP < 400 ng/ml HBV or HCV infection (-) (+) 2nd Liver biopsy Follow every 2 months Characteristic CT scan / MRI Liver tumor Characteristic or Non-characteristic CT scan / MRI or non-increase AFP AFP ≥ 400 ng/ml Best Supportive Care 6

RESULTS

SEX DISTRIBUTION

Number of new HCC patients per year Sex distribution  Female 4395 (18.24%) Total 24091 patients  Male 19696 (81.76%)

Comments Number of HCC patients coming to Liver Tumor Department Cho Ray Hospital increases by year  necessary surveillance of HCC on high risk group by US + AFP every 6 months (according to APASL), and using biomarkers AFP-L3 and PIVKA II (DCP) Male / Female ratio : 4.48 / 1

AGE DISTRIBUTION

Number of new HCC patients per year Age distribution 15-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 0.29% 1.59% 6.61% 17.64% 29.92% 24.86% 19.08%

Number of new HCC patients per year Age distribution 15-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 2010 2011 2012 2013 2014 2015 2016

Comments 91.51% HCC patients > 40 yo. Most patients are in the age of 50-60 (29.92%) Causes Natural history from hepatitis virus infection to HCC # 15 years HBV vaccination just started # 15 years

GEOGRAPHIC DISTRIBUTION

Geographic distribution New HCC patients Geographic distribution

New HCC patients Region distribution

New HCC patients - Region distribution Mekong river Delta 2010 2011 2012 2013 2014 2015 2016 South East Middle South HCMC Highland Other

POSSIBILITY OF TREATMENT

Number of new HCC patients in far advanced stage  Female 1336 pts (13.60%)  Male 8491 pts (86.40%) 9827 / 24091 patients (40.79%)

Number of new HCC patients in far advanced stage / New HCC patients 40.59% 43.68% 40.51% 37.64% 40.78% 40.74% 41.68%

Number of new HCC patients in far advanced stage Sex distribution  Female 1336 (13.60%) Total 9827 patients  Male 8491 (86.40%)

Number of new HCC patients in far advanced stage Age distribution 15-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 0.30% 1.67% 8.06% 21.15% 31.03% 21.69% 16.12%

Number of new HCC patients in far advanced stage Age distribution 15-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 2010 2011 2012 2013 2014 2015 2016

Number of new HCC patients Age distribution 15-20 >20-30 >30-40 >40-50 >50-60 >60-70 >70 2010 2011 2012 2013 2014 2015 2016 Number of new HCC patients in far advanced stage Age distribution

Comments 40.79% new HCC patients are already in far advanced stage 89.98% of those patients ≥ 40 yo., mostly > 50-60 yo. Causes HCC usually progresses in silence HCC usullaly do not has clinical symptoms Surveillance on high risk group is limited Limited consciousness of people for health check Low effect of hepatitis virus treatment

HEPATITIS VIRUS INFECTION RELATIONSHIP WITH HEPATITIS VIRUS INFECTION

Relationship HCC – Hepatitis virus infection (All new HCC patients) Liver Tumor Dept – Cho Ray hospital 2010-2016 : 24092 new HCC patients 9827 (40.79%) new HCC patients in far advanced stage 24091 new HCC patients : 21584 patients (89.59%) were checked of HBsAg & AntiHCV : HBV 62.28 % HBV & HCV 2.68 % HCV 26.07 % No infection 8.97 %  19648 patients (91.03%) related to hepatitis virus infection 9827 new HCC patients in far advanced stage : 8595 patients (87.46%) were checked of HBsAg & AntiHCV : HBV 68.71 % HBV & HCV 2.20 % HV 19.73 % No infection 9.35 %  7791 patients (90.65%) related to hepatitis virus infection

Relationship HCC – Hepatitis virus infection 2010 2011 2012 2013 2014 2015 2016 HBV infection HCV infection HBV & HCV infection No infection Not recorded

9827 / 24091 patients Relationship HCC – Hepatitis virus infection (Far advanced HCC patients group) 2010 2011 2012 2013 2014 2015 2016 HBV infection HCV infection HBV & HCV infection No infection Not recorded 9827 / 24091 patients

Comments Causes of HCC in Vietnam close relationship with hepatitis virus infection most popular is HBV infection HBV / HCV infection ratio is 2.39 / 1 (all new patients) 3.48 / 1 (far advanced HCC patients group)  any difference in the development of HCC ? HCV infection rate is increasing No infection rate is increasing

New HCC patients - Region distribution Relationship HCC – Hepatitis virus infection HBV infection HCV infection HBV & HCV infection No infection Not recorded New HCC patients per year transferred from Regions New HCC patients per year already in far advanced stage transferred from Regions

DIAGNOSTIC ROLE OF AFP

AFP in new HCC patients < 20 ng/ml 23.21% > 20-100 ng/ml 14.61% Not recorded 1.89%

Comments AFP has limited value in diagnosis of HCC New biomarkers are useful for surveillance, diagnosis and follow up of HCC AFP-L3 and PIVKA II (DCP) Used first time in Vietnam at Cho Ray hospital Hope to improve HCC surveillance in Vietnam

CONCLUSION

High incidence of HCC in Vietnam Close relationship with hepatitis virus infection Most patients come to high level hospitals  overload Not so much attention on HCC surveillance from both medical staff and high risk people sites Management of viral hepatitis patients is not so good Relative low result of viral hepatitis treatment

THANK YOU FOR YOUR KIND ATTENTION