Korean clinical practice guideline for pancreatic cancer 2021: A summary of evidence-based,multi-disciplinary diagnostic and therapeutic approaches

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related death in Korea. To enable standardization of management and facilitate improvements in outcome, a total of 53 multi-disciplinary experts in gastroenterology, surgery, medical oncology, radiation oncology, radiology, nuclear medicine, and pathology in Korea developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. Recommendations were made on imaging diagnosis, endoscopic management, surgery, radiotherapy, palliative chemotherapy, and specific management procedures, including neoadjuvant treatment or adjuvant treatment for patients with resectable, borderline resectable, and locally advanced unresectable pancreatic cancer.This is the English version of the Korean clinical practice guideline for pancreatic cancer 2021. This guideline includes 20 clinical questions and 32 statements. This guideline represents the most standard guideline for the diagnosis and treatment of patients with pancreatic ductal adenocarcinoma in adults at this time in Korea. The authors believe that this guideline will provide useful and informative advice.     

Canadian Thoracic Society: Presenting a new process for clinical practice guideline production

A key mandate of the Canadian Thoracic Society (CTS) is to promote evidence-based respiratory care through clinical practice guidelines (CPGs). To improve the quality and validity of the production, dissemination and implementation of its CPGs, the CTS has revised its guideline process and has created the Canadian Respiratory Guidelines Committee to oversee this process. The present document outlines the basic methodological tools and principles of the new CTS guideline production process. Important features include standard methods for choosing and formulating optimal questions and for finding, appraising, and summarizing the evidence; use of the Grading of Recommendations Assessment, Development and Evaluation system for rating the quality of evidence and strength of recommendations; use of the Appraisal of Guidelines for Research and Evaluation instrument for quality control during and after guideline development and for appraisal of other guidelines; use of the ADAPTE process for adaptation of existing guidelines to the local context; and use of the GuideLine Implementability Appraisal tool to augment implementability of guidelines. The CTS has also committed to develop guidelines in new areas, an annual guideline review cycle, and a new formal process for dissemination and implementation. Ultimately, it is anticipated that these changes will have a significant impact on the quality of care and clinical outcomes of individuals suffering from respiratory diseases across Canada.     

Usefulness of surveillance programmes for early diagnosis of hepatocellular carcinoma in clinical practice

Background/Aims: Surveillance programmes (SPs) for hepatocellular carcinoma (HCC) in patients with cirrhosis intend to diagnose the tumour in its early stages when an effective therapy can be applied. The aims of this study have been to compare the survival of patients with HCC being diagnosed or not in SPs, and to establish a more accurate profile of the best target population. Methods: From January 1996 to June 2005, 290 patients with HCC were included. The relationship between being diagnosed or not in an SP and survival has been analysed in a univariate analysis. Pretreatment variables found to be significant predictors of survival in univariate analysis were included in a multivariate analysis. Results: The mean survival for patients diagnosed in SPs (27 months, 16.6–37.4) was significantly longer than in patients being diagnosed out of these programmes (6 months, 2.6–9.4) (P=0.001). Child–Pugh class A [β 1.4, 95% confidence interval (CI) 1.14–1.78; P=0.0002] and being diagnosed in SPs (β 0.4, 95% CI 0.3–0.6; P=0.0003) became the only independent predictive factors of longer survival. Conclusions: SPs for HCC allow the detection of small tumours and the application of intention‐to‐cure therapies, which improves survival. However, these programmes do not improve prognosis in patients with advanced cirrhosis.     

Critical appraisal of clinical practice guidelines for diagnosis and treatment of hepatocellular carcinoma

Background and Aim: Hepatocellular carcinoma (HCC) is the third most common reason for cancer‐related death worldwide. Many countries either lack appropriate clinical practice guidelines for the diagnosis and treatment of HCC or the quality of their guidelines has never been evaluated. The main objective of our work was to identify published HCC guidelines and assess their quality with the Appraisal of Guidelines for Research and Evaluation instrument (AGREE) and their suitability regarding adaptation for future guidelines. Methods: We performed a systematic literature search on HCC clinical practice guidelines of MEDLINE, National Guidelines Clearinghouse and the Guidelines International Network. Methodological quality of selected guidelines was assessed by the AGREE instrument, Version 2001. Results: A total of 286 citations were screened and 32 relevant guidelines were identified. Overall, the guidelines performed well in the clarity and presentation domain with a mean score of 67%, followed by scope and purpose (55%) and rigor of development (50%). In contrast, poor scores were given for the remaining domains: stakeholder involvement (23%), applicability (28%) and editorial independence (31%). According to the AGREE instrument, four guidelines can be strongly recommended, 18 with provisos and alterations while the remaining cannot be recommended for adaptation due to poor methodological quality. Conclusion: Although existing HCC guidelines may accurately reflect agreed clinical practice, many guidelines lack proper methodological quality. Future guidelines should place more emphasis on these methodological shortcomings.     

老年科良性前列腺增生的诊治现状

目的 了解良性前列腺增生(benign prostate hyperplasia,BPH)在老年科的诊断和治疗现状,促进BPH诊断和治疗的规范化.方法 抽取我国23个城市的老年科门诊BPH患者,完成老年科BPH门诊登记调查表.问卷内容包括患者的基本情况、诊疗情况和治疗效果.结果 对4001份调查问卷的分析显示,患者平均国际前列腺症状评分(IPSS)(18.8±5.9)分,中、重度症状患者分别占53.8％和42.0％.并存疾病的患病率依次为高血压(63.9％)、冠心病(40.4％)、糖尿病(32.4％)和高脂血症(25.7％).BPH相关并发症的发生率依次为尿路感染(21.0％)、尿路结石(8.3％)、反复血尿(1.8％)、肾积水(1.7％)和疝气(0.6％).医师采用的诊疗手段中,未进行直肠指诊的占27.2％,未进行血清前列腺特异性抗原(PSA)检查的占89.5％.在药物治疗的患者中,68.1％的患者处方中有a受体阻滞剂,92.9％的处方中有5α还原酶抑制剂,11.8％的处方中有中药和植物制剂,0.4％的处方中有M受体阻滞剂.首次处方中,单药治疗的占51.1％,2种药物联合治疗的占46.6％.在中重度症状患者中,遵医嘱规律服药的占60.6％,已停药的占13.9％.需要调整处方的原因依次为药物疗效差(23.4％)、不良反应多(5.4％)、价格昂贵(3.5％)、服用不方便(2.9％)等.结论 老年科门诊BPH患者以中重度症状为主,BPH治疗的同时还需考虑并存的疾病和BPH相关并发症;医师需进一步认识直肠指诊和PSA检查的重要性,联合治疗对于改善患者下尿路症状效果显著,长期治疗效果更好.     

Guide for diagnosis and treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is ranked as the 5^th common type of cancer worldwide and is considered as the 3^rd common reason for cancer-related deaths. HCC often occurs on top of a cirrhotic liver. The prognosis is determined by several factors; tumour extension, alpha-fetoprotein (AFP) concentration, histologic subtype of the tumour, degree of liver dysfunction, and the patient’s performance status. HCC prognosis is strongly correlated with diagnostic delay. To date, no ideal screening modality has been developed. Analysis of recent studies showed that AFP assessment lacks adequate sensitivity and specificity for effective surveillance and diagnosis. Many tumour markers have been tested in clinical trials without progressing to routine use in clinical practice. Thus, surveillance is still based on ultrasound (US) examination every 6 mo. Imaging studies for diagnosis of HCC can fall into one of two main categories: routine non-invasive studies such as US, computed tomography (CT), and magnetic resonance imaging, and more specialized invasive techniques including CT during hepatic arteriography and CT arterial portography in addition to the conventional hepatic angiography. This article provides an overview and spotlight on the different diagnostic modalities and treatment options of HCC.     

Effect of surveillance for hepatocellular carcinoma on tumor staging and treatment decisions in Egyptian patients

Purpose  

Egyptian hepatocellular carcinoma (HCC) patients present at advanced stages. We aimed to study the influence of surveillance versus non-surveillance on HCC staging and the potential therapeutic options.     

美国、亚太和中国肝癌共识比较

原发性肝癌是临床上常见的恶性肿瘤,规范化诊疗在国内外均引起高度关注,美国肝病研究学会、亚太肝脏研究学会及中国抗癌协会肝癌专业委员会和临床肿瘤学协作专业委员会以及中华医学会肝病学会肝癌学组均制定了原发性肝癌规范化诊治专家共识或诊治指南,本文通过对美国、亚太和中国肝癌共识进行比较,分析其对肝癌诊治临床实践的参考价值和指导意义。     

甲胎蛋白异质体对诊断肝细胞癌的相关价值研究

目的评价甲胎蛋白异质体(AFP-L3)对于原发性肝癌(PHC)的诊断价值。方法收集本院2013年1月至2013年7月住院及门诊患者185例,包括PHC患者61例(PHC组)、肝硬化患者66例(肝硬化组)、慢性活动性肝炎患者58例(慢性肝炎组)。选择同期健康体检者60例为对照组。AFP-L3采用亲和吸附离心管分离血清,AFP和AFP-L3水平采用化学发光法检测,以AFP-L3≥10%为阳性诊断标准,计算AFP-L3的百分含量。结果 PHC组、肝硬化组、慢性肝炎组、对照组患者血清AFP-L3阳性率分别为78.02%、69.8%、78.26%、0%。PHC组患者AFP-L3水平与肝硬化组比较,差异无统计学意义(P=0.062)。PHC组患者AFP-L3水平与对照组比较,差异有统计学意义(P=0.031)。结论AFP-L3是国际公认的对PHC鉴别诊断的有用指标,但本研究显示其在良性肝病特别是肝硬化与PHC差别不明显,因此仍应与AFP及影像学联合检测更有利于PHC的诊断。     

The surveillance and diagnosis of hepatocellular carcinoma

The increasing incidence of hepatocellular carcinoma (HCC) is becoming a considerable problem in Europe. While no national surveillance programme exists, there is increasing evidence that surveillance programmes are efficacious and may be cost-effective. The prognosis of large, symptomatic HCC is poor and only palliative treatment is available. In contrast small tumours are now amenable to several modes of treatment including liver transplantation, surgical resection and loco-regional ablation with acceptable 5 year survival rates. Therefore, the identification of small lesions through screening should prolong survival. Consequently, the European Association for the Study of the Liver (EASL) has recommended surveillance with ultrasound scans and tests for alpha fetoprotein every 6 months. Screening is now routine clinical practice in many parts of the developed world.     

Controversies in staging of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver. As the natural history of HCC is better delineated, treatment strategies are in constant evolution. Classic staging systems based on histopathology following resection are often inadequate because the majority of patients present with advanced disease. The dissatisfaction with anatomic staging systems has resulted in the emergence of several new clinical staging systems, which attempt to integrate tumor biology and the underlying function of the nondiseased liver. Tragically, the byproduct of multiple staging strategies is confusion for physicians, patients, and clinical researchers; this undermines the principles on which staging systems are created. To address this issue, a consensus conference was organized in 2002 to identify the best staging strategy for HCC. The purpose of this article is to review the current clinical and pathologic staging strategies and to highlight the recommendations from the consensus conference.     

原发性肝癌诊疗规范（2011年版）

一、概述原发性肝癌（primarylivercancer,PLC,以下简称肝癌）是常见恶性肿瘤。由于起病隐匿,早期没有症状或症状不明显,进展迅速,确诊时大多数患者已经达到局部晚期或发生远处转移,治疗困难,预后很差,如果仅采取支持对症治疗,自然生存时问很短,严重地威胁人民群众的身体健康和生命安全。     

Clinical characteristics, staging and treatment of patients with hepatocellular carcinoma in clinical practice. Prospective study of 136 patients

Hepatocellular carcinoma (HCC) is the most frequent cause of mortality in patients with liver cirrhosis. There are no prospective series from a single tertiary hospital in Spain.

Material and Methods

We performed a prospective study of patients with HCC in our center. Clinical and epidemiological characteristics, diagnostic method, staging according to the Barcelona Clinic Liver Cancer (BCLC) system and treatment were analyzed.

Results

A total of 136 patients were included (80.9% men). The mean age was 66.62±11.68 years and 91.2% were cirrhotic. Hepatitis C virus (HCV) was the leading cause of liver disease (38.97%). The suspected diagnosis was established by a surveillance program in 63.2%. Noninvasive American Association criteria for the Study of Liver Diseases (AASLD) were the main diagnostic method (73.5%). According to the BCLC, 58.1% were in the early stage (0-A), 21.3% in stage B, 12.5% in stage C and 8.1% in stage D. Early stage patients had followed a surveillance program more frequently than those with non-early stages (79.75% versus 44.35%, p <0.001). Potentially curative initial treatment was used in 45.58%, the most common treatment being percutaneous ethanol injection (23.13%).

Conclusions

Most patients with HCC in our hospital have cirrhosis, the most frequent cause being HCV. HCC surveillance in at-risk patients could increase diagnosis of HCC at an early stage. We achieved an early diagnosis in more than half of cases. The most common initial treatment was percutaneous therapy.     

Current and future treatments for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents a unique challenge for physicians and patients. There is no definitively curative treatment. Rather, many treatment and management modalities exist with differing advantages and disadvantages. Both current guidelines and individual patient concerns must be taken into account in order to properly manage HCC. In addition, quality of life issues are particularly complex in patients with HCC and these concerns must also be factored into treatment strategies. Thus, considering all the options and their various pros and cons can quickly become complex for both clinicians and patients. In this review, we systematically discuss the current treatment modalities available for HCC, detailing relevant clinical data, risks and rewards and overall outcomes for each approach. Surgical options discussed include resection, transplantation and ablation. We also discuss the radiation modalities: conformal radiotherapy, yttrium 90 microspheres and proton and heavy ion radiotherapy. The biologic agent Sorafenib is discussed as a promising new approach, and recent clinical trials are reviewed. We then detail currently described molecular pathways implicated in the initiation and progression of HCC, and we explore the potential of each pathway as an avenue for drug exploitation. We hope this comprehensive and forward-looking review enables both clinicians and patients to understand various options and thereby make more informed decisions regarding this disease.     

Indications of external radiotherapy for hepatocellular carcinoma from updated clinical guidelines: Diverse global viewpoints

significantly vary among regions.Modern standard treatments commonly require multidisciplinary approaches,including applications of up-to date medicine and advanced procedures,and necessitate the support of socioeconomic systems.For these reasons,a number of clinical guidelines for HCC from different associations and regions have been presented.External beam radiation therapy was contraindicated for HCC until a few decades ago,but with the development of new technologies,its application has rapidly increased as selective irradiation for tumorous lesions became possible.Most of the guidelines had been opposed or indifferent to radiotherapy in the past,but several guidelines have introduced indications and recommendations for radiotherapy in their updated versions.This review will discuss the characteristics of important guidelines and their contents regarding radiotherapy and will also provide guidance to physicians who are considering applications of locoregional modalities that include radiotherapy.     

Positron emission tomography/computed tomography with 18F-fluorocholine improve tumor staging and treatment allocation in patients with hepatocellular carcinoma

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Surveillance for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) appears mainly in patients with underlying liver disease and it is recognized as one of the most important causes of death in this population. Early detection by surveillance has been suggested as an effective tool for reducing cancer-specific mortality and the most accepted strategy is semiannual abdominal ultrasound in those patients at risk of HCC development. The benefit of HCC surveillance is proven by a randomized-controlled study, several prospective or retrospective analyses, and multiple modeling studies and according to the current scientific evidence, surveillance of HCC should be recommended and widely implemented. Major efforts should be done for improving the diagnostic accuracy of the screening tools and for better identifying those patients at risk of HCC development in whom a surveillance program would be cost-effective.     

Viral hepatitis and hepatocellular carcinoma: From molecular pathways to the role of clinical surveillance and antiviral treatment

Hepatocellular carcinoma (HCC) is a global health challenge. Due to the high prevalence in low-income countries, hepatitis B virus (HBV) and hepatitis C virus infections remain the main risk factors for HCC occurrence, despite the increasing frequencies of non-viral etiologies. In addition, hepatitis D virus coinfection increases the oncogenic risk in patients with HBV infection. The molecular processes underlying HCC development are complex and various, either independent from liver disease etiology or etiology-related. The reciprocal interlinkage among non-viral and viral risk factors, the damaged cellular microenvironment, the dysregulation of the immune system and the alteration of gut-liver-axis are known to participate in liver cancer induction and progression. Oncogenic mechanisms and pathways change throughout the natural history of viral hepatitis with the worsening of liver fibrosis. The high risk of cancer incidence in chronic viral hepatitis infected patients compared to other liver disease etiologies makes it necessary to implement a proper surveillance, both through clinical-biochemical scores and periodic ultrasound assessment. This review aims to outline viral and microenvironmental factors contributing to HCC occurrence in patients with chronic viral hepatitis and to point out the importance of surveillance programs recommended by international guidelines to promote early diagnosis of HCC.     

美国肝病研究学会肝细胞癌诊治指南要点

1要点 在许多国家,肝癌（HCC）的发生率逐渐升高。肝癌患者的治疗需要多学科的参与,包括肝脏内科、外科、肝移植小组、肿瘤科、介入科及放疗科。HCC的发生通常有相关的肝病背景,因此在治疗前、治疗过程中及治疗后对肝功能损害的评估显得尤为重要。