Chemoembolization for unresectable hepatocellular carcinoma(HCC)-Standard Treatment Guidelines

Introduction

The treatment of choice for HCC remains surgical resection or liver transplanation, however, in a non-surgical case a variety of percutaneous therapeutic interventional palliative treatment techniques such as transcatheter arterial chemoembolization (TACE), transcatheter arterial radio- embolization (TART) and percutaneous ablative therapies like radiofrequency ablation (RFA) are available (1- 3).

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Chemoembolization for unresectable hepatocellular carcinoma(HCC).
Following are the major recommendations :

Case definition
For both situations of care (mentioned below)

A clinically or radiologically suspected, biopsy or laboratory proved case of hepatocellular carcinoma.

INCIDENSE OF THE CONDITION IN OUR COUNTRY

HCC is one of the common cancer and the cause of cancer related death in the world. It's incidence in India is also increasing due to increase in incidence of cirrhosis and hepatitis B&C.

DIFFERENTIAL DIAGNOSIS-Liver metastasis, benign hepatic lesion.

PREVENTION AND COUNSELLING-Since HBV is the most common etiologic agent in our country, the vaccination against hepatitis B may be an effective preventive strategy.

The other cause such as alcohol induced cirrhosis may be avoided by avoidance of alcohol.

Proper counseling of patient by explaining him various non-surgical interventional treatment options and their outcome should be explained to every patient.

OPTIMAL DIAGNOSTIC CRITERIA, INVESTIGATIONS, TREATMENT & REFERRAL CRITERIA :

Diagnostic criteria / investigations-

Clinical -features of cirrhosis & palpable mass.
Biochemical -Serum alpha fetoprotein (AFP), viral markers (HBV & HCV)
Radiological - Imaging features on US, CT & MR.
Histological - Fine needle aspiration cytology or biopsy as & when required.

Treatment-Chemoembolization for unresectable tumour with child's class A & B.

1. Tumour size > 5 cm in diameter.


2. Tumour size > 3 cm in diameter and 2 or 3 in number.


3. Treatable size tumour with ipsilateral portal vein invasion.

Referral criteria-

Patient fit for chemoembolization is treated with angiographic treatment. If angiographic facility is not available at the hospital, patient is referred to the hospital with such treatment facilities.

Situation 1 : At Secondary Hospital / Non-Metro situation : Optimal Standards of Treatment in situations where technology and resources are limited.

Clinical Diagnosis: Clinical features of cirrhosis &/or palpable mass.
Investigations :
Biochemical- Serum alpha fetoprotein (AFP), viral markers (HBV & HCV)
Radiological- Imaging features on US, CT & MR.
Histological- Fine needle aspiration cytology or biopsy as & when required.

Treatment : chemoembolization for unresectable tumour with
Child's class A & B.

Standard operating procedure

In Patient - Chemoembolization is performed as indoor case
Out Patient - Not applicable
Day Care - Not applicable

Referral criteria :

If facilities for standard treatment are not available, patient is referred to super specialty hospital where these facilities are available.

Situation 2 : At super specialty facility in metro location where higher-end technology is available.

Clinical Diagnosis :Clinical features of cirrhosis &/or palpable mass.

Investigations :Biochemical – Serum alpha fetoprotein (AFP), viral markers (HBV & HCV)
Radiological – Imaging features on US, CT & MR.
Histological – Fine needle aspiration cytology or biopsy as & when required.

Treatment : Chemoembolization for unresectable tumour with Child's class A & B.

Standard operating procedure

In Patient - Chemoembolization is performed as indoor case
Out Patient - Not applicable
Day Care - Not applicable
Referral criteria : Not applicable

RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (PATIENT WEIGHT 60 KGS)

(Units to be specified for human resources, investigations, drugs and consumables and equipment. Quantity to also be specified)

SITUATION	HUMAN RESOURCES	INVESTIGATIONS	DRUGS & CONSUMABLES	EQUIPMENT
1.	(Radiologists-2 Anaesthetist -1 Clinician - 1) Technicians –2 Nurses – 2 Orderly / Ward Boy - 2	1. Routine blood examination Hb, TLC, DLC etc. 2. S. alfa feto protein 3. Serum HBV & HCV 4. Liver function tests 5. Blood sugar etc	1. Doxorubicin 50 – 100 mg. 2. Other chemotherapeutic drugs as per case 3. Lipiodol 20 ml 4. Angiographic catheters (4 –5 F) 5. Microcatheter (3F) 6. Gel foam 7. PVA 3/4 vials	Digital subtraction angiography equipment with life saving devices and Ultrasound (colour Doppler) equipment
2.	Same as mentioned above	Same as mentioned above	Same as mentioned above	Same as mentioned above

Guidelines by The Ministry of Health and Family Welfare :

Dr. Chander Mohan
Dr. B.L. Kapur Hospital
New Delhi