2019 Update of Indian National Association for Study of the Liver Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri II Recommendations

Abstract

Hepatocellular carcinoma (HCC) is one of the major causes of morbidity, mortality, and healthcare expenditure in patients with chronic liver disease in India. The Indian National Association for Study of the Liver (INASL) had published its first guidelines on diagnosis and management of HCC (The Puri Recommendations) in 2014, and these guidelines were very well received by the healthcare community involved in diagnosis and management of HCC in India and neighboring countries. However, since 2014, many new developments have taken place in the field of HCC diagnosis and management, hence INASL endeavored to update its 2014 consensus guidelines. A new Task Force on HCC was constituted that reviewed the previous guidelines as well as the recent developments in various aspects of HCC that needed to be incorporated in the new guidelines. A 2-day round table discussion was held on 5th and 6th May 2018 at Puri, Odisha, to discuss, debate, and finalize the revised consensus statements. Each statement of the guideline was graded according to the Grading of Recommendations Assessment Development and Evaluation system with minor modifications. We present here the 2019 Update of INASL Consensus on Prevention, Diagnosis, and Management of Hepatocellular Carcinoma in India: The Puri-2 Recommendations.

Keywords: AFP, alpha-fetoprotein; AIH, autoimmune hepatitis; ALT, alanine aminotransferase; DAA, direct-acting antiviral; DALY, disability-adjusted life-year; DNA, deoxyribonucleic acid; GRADE, Grading of Recommendations Assessment Development and Evaluation; Gd-BOPTA, gadolinium benzyloxypropionictetraacetate; Gd-EOB-DTPA, gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid; HBV, hepatitis B virus; HBeAg, hepatitis B envelope antigen; HCC, hepatocellular carcinoma; HIV, human immunodeficiency virus; IARC, International Agency for Research on Cancer; IFN, interferon; INASL, Indian National Association for Study of the Liver; MiRNA, micro-RNA; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; PIVKA, protein induced by vitamin K absence; RFA; RNA, ribonucleic acid; SVR, sustained virological response; TACE; TACE, trans-arterial chemoembolization; TARE, transarterial radioembolization; TNF, tumor necrosis factor; WHO, World Health Organization; liver cancer; targeted therapy; transplant.

Figure 1

INASL-modified BCLC staging. INASL, Indian National Association for Study of the Liver; BCLC, Barcelona-Clinic Liver Cancer; TACE, transarterial chemoembolization; TARE, transarterial radioembolization; SBRT, stereotactic body radiotherapy.