Incidence and morbidity of infection by hepatitis C virus in children with acute lymphoblastic leukaemia

Screening and prevention of hepatitis C virus reactivation during chemotherapy

Hepatitis C virus (HCV) reactivation occurs in 23% of HCV-infected cancer patients receiving chemotherapy. Forty-three percent of the patients with reactivation of HCV during chemotherapy develop a hepatitis flare. Most of the cancer patients with HCV reactivation have an unremarkable clinical course following an HCV-related hepatitis flare during chemotherapy. However, 26%–57% of the cancer patients developing an acute flare of chronic hepatitis C during chemotherapy require unanticipated discontinuation or dose reduction of chemotherapy, which results in deleterious changes in the cancer treatment plan. Although an optimal strategy for HCV screening in cancer patients receiving chemotherapy has not been established, universal pre-chemotherapy HCV testing for patients with hematological malignancies is recommended by current guidelines. All the currently approved direct-acting antivirals (DAAs) can be used in cancer patients, but the use of DAAs during chemotherapy should avoid drug–drug interactions between chemotherapy and antiviral agents. If there are no contraindications or anticipated drug–drug interactions, DAAs treatment can be administered before, during, or after chemotherapy. In conclusion, HCV reactivation occurs in approximately one-fourth of HCV-infected cancer patients receiving chemotherapy. An HCV-related hepatitis flare during chemotherapy may lead to the discontinuation of potentially life-saving chemotherapy. Currently, universal HCV screening is recommended in hematological malignancy patients before chemotherapy, but there is no evidence-based guideline for other cancer patients. DAAs treatment can cure HCV infection and prevent HCV reactivation during chemotherapy.

Hepatitis C Virus Infection in Children and Pregnant Women: An Updated Review of the Literature on Screening and Treatments

Objective  The aim of the paper is to review the current information relating to the diagnosis and treatment of hepatitis C virus (HCV) infection in pregnant women and children, particularly those infected by mother-to-child transmission. Study Design  A review of published literature was performed to identify relevant articles published between January 2015 and March 2019 on: HCV infection in pregnant woman, mother-to child-transmission of HCV and HCV infection in pediatrics. The results of the evaluation of the different studies were summarized in two sections describing separately the screening and effective treatments in pregnant women and children. Results  The rate of mother-to-child transmission of HCV is approximately 5%. HCV infection is strongly associated with cholestasis and preterm birth. Prenatal diagnosis of hepatitis C virus has a dual benefit for mother and child. Perinatally infected children develop cirrhosis in earlier age than those who acquire HCV as adolescents. Pregnant women with cirrhosis have a higher risk of poor maternal and neonatal outcomes than those without cirrhosis. Conclusion  To improve public health, universal screening of pregnant women for HCV infection should be performed. Early identification of women and children with HCV infection is important to enable them to be included in assessment and/or treatment programs.

Hepatic late adverse effects after antineoplastic treatment for childhood cancer

BACKGROUND

Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately, the improved prognosis has been accompanied by the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors, the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies, it is important to know the risk of, and associated risk factors for, hepatic late adverse effects. This review is an update of a previously published Cochrane review.

OBJECTIVES

To evaluate all the existing evidence on the association between antineoplastic treatment (that is, chemotherapy, radiotherapy involving the liver, surgery involving the liver and BMT) for childhood cancer and hepatic late adverse effects.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2018, Issue 1), MEDLINE (1966 to January 2018) and Embase (1980 to January 2018). In addition, we searched reference lists of relevant articles and scanned the conference proceedings of the International Society of Paediatric Oncology (SIOP) (from 2005 to 2017) and American Society of Pediatric Hematology/Oncology (ASPHO) (from 2013 to 2018) electronically.

SELECTION CRITERIA

All studies, except case reports, case series, and studies including fewer than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment).

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection and 'risk of bias' assessment. The 'risk of bias' assessment was based on earlier checklists for observational studies. For the original version of the review, two review authors independently performed data extraction. For the update of the review, the data extraction was performed by one reviewer and checked by another reviewer.

MAIN RESULTS

Thirteen new studies were identified for the update of this review. In total, we included 33 cohort studies including 7876 participants investigating hepatic late adverse effects after antineoplastic treatment (especially chemotherapy and radiotherapy) for different types of childhood cancer, both haematological and solid malignancies. All studies had methodological limitations. The prevalence of hepatic late adverse effects, all defined in a biochemical way, varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well-defined as alanine aminotransferase (ALT) above the upper limit of normal, indicating cellular liver injury, resulted in eight studies. In this subgroup, the prevalence of hepatic late adverse effects ranged from 5.8% to 52.8%, with median follow-up durations varying from three to 23 years since cancer diagnosis in studies that reported the median follow-up duration. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal, resulted in five studies, with a prevalence ranging from 0.9% to 44.8%. One study investigated biliary tract injury, defined as gamma-glutamyltransferase (γGT) above the upper limit of normal and above twice the upper limit of normal and reported a prevalence of 5.3% and 0.9%, respectively. Three studies investigated disturbance in biliary function, defined as bilirubin above the upper limit of normal and reported prevalences ranging from 0% to 8.7%. Two studies showed that treatment with radiotherapy involving the liver (especially after a high percentage of the liver irradiated), higher BMI, and longer follow-up time or older age at evaluation increased the risk of cellular liver injury in multivariable analyses. In addition, there was some suggestion that busulfan, thioguanine, hepatic surgery, chronic viral hepatitis C, metabolic syndrome, use of statins, non-Hispanic white ethnicity, and higher alcohol intake (> 14 units per week) increase the risk of cellular liver injury in multivariable analyses. Chronic viral hepatitis was shown to increase the risk of cellular liver injury in six univariable analyses as well. Moreover, one study showed that treatment with radiotherapy involving the liver, higher BMI, higher alcohol intake (> 14 units per week), longer follow-up time, and older age at cancer diagnosis increased the risk of biliary tract injury in a multivariable analysis.

AUTHORS' CONCLUSIONS

The prevalence of hepatic late adverse effects among studies with an adequate outcome definition varied considerably from 1% to 53%. Evidence suggests that radiotherapy involving the liver, higher BMI, chronic viral hepatitis and longer follow-up time or older age at follow-up increase the risk of hepatic late adverse effects. In addition, there may be a suggestion that busulfan, thioguanine, hepatic surgery, higher alcohol intake (>14 units per week), metabolic syndrome, use of statins, non-Hispanic white ethnicity, and older age at cancer diagnosis increase the risk of hepatic late adverse effects. High-quality studies are needed to evaluate the effects of different therapy doses, time trends, and associated risk factors after antineoplastic treatment for childhood cancer.

Study of the Associations Between TT Virus Single and Mixed Infections With Leukemia

BACKGROUND

The pathogenic association of Transfusion Transmitted Virus or Torque teno Virus (TT Virus) single and mixed infections with leukemia was under evaluation in these years but confront with controversies. This hypothesis is based on the higher prevalence of TT Virus infection in patients with leukemia compared with controls.

OBJECTIVES

The aim of this study was to determine the frequency of TT Virus, Cytomegalovirus (CMV), Hepatitis B Virus (HBV), and Hepatitis C Virus (HCV) infections in patients with leukemia and healthy controls.

PATIENTS AND METHODS

In this cross sectional study, 95 patients with leukemia and 100 healthy controls who were admitted to the Namazi Hospital affiliated to the Shiraz University of Medical Sciences, Shiraz, Iran, were enrolled between years 2012 and 2013. Blood samples treated with EDTA were collected from each patient with leukemia and controls. The existence of TT Virus infection was analyzed using the semi-nested PCR method. The immunological prevalence of HBV and HCV infections were evaluated using HBs-Ag and HCV-Ab ELISA based protocols, respectively. Active CMV infection was also evaluated using an immunofluorescence method. Also risk factors of leukemia and viral infections were statistically analyzed in patients with leukemia.

RESULTS

The TT Virus infection was significantly found in 40 of 95 (42.1%) and 12 of 100 (12%) patients with leukemia and controls, respectively. The HBs-Ag and HCV-Ab were detected in 27 of 95 (28.4%) and 18 of 69 (26.1%) patients with leukemia but were not found in the controls. Active CMV infection was also found in 11 of 69 (16%) patients and none of the controls. Significant co-infection of TT Virus was found with HBV (15 of 40; 37.5%), HCV (14 of 40; 35%) and CMV (7 of 40; 17.5%) in patients with leukemia.

CONCLUSIONS

Confirmation of the significantly higher frequency of TT Virus, HBV, HCV and CMV single infection and their co-infection in patients with leukemia compared with healthy controls, emphasizes the determinative role of TT Virus pathogenesis in clinical outcomes observed in patients with leukemia, which requires extensive evaluation by further studies.

Hepatic late adverse effects after antineoplastic treatment for childhood cancer

BACKGROUND

Survival rates have greatly improved as a result of more effective treatments for childhood cancer. Unfortunately the improved prognosis has resulted in the occurrence of late, treatment-related complications. Liver complications are common during and soon after treatment for childhood cancer. However, among long-term childhood cancer survivors the risk of hepatic late adverse effects is largely unknown. To make informed decisions about future cancer treatment and follow-up policies it is important to know the risk of, and associated risk factors for, hepatic late adverse effects.

OBJECTIVES

To evaluate the existing evidence on the association between antineoplastic treatment for childhood cancer and hepatic late adverse effects.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to June 2009) and EMBASE (1980 to June 2009). In addition, we searched reference lists of relevant articles and conference proceedings.

SELECTION CRITERIA

All studies except case reports, case series and studies including less than 10 patients that examined the association between antineoplastic treatment for childhood cancer (aged 18 years or less at diagnosis) and hepatic late adverse effects (one year or more after the end of treatment).

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the study selection, risk of bias assessment and data extraction.

MAIN RESULTS

We identified 20 cohort studies investigating hepatic late adverse effects after antineoplastic treatment for childhood cancer. All studies had methodological limitations. The prevalence of hepatic late adverse effects varied widely, between 0% and 84.2%. Selecting studies where the outcome of hepatic late adverse effects was well defined as alanine aminotransferase (ALT) above the upper limit of normal resulted in five studies. In this subgroup the prevalence of hepatic late adverse effects ranged from 8.0% to 52.8%, with follow-up durations varying from one to 27 years after the end of treatment. A more stringent selection process using the outcome definition of ALT as above twice the upper limit of normal resulted in three studies, with a prevalence ranging from 7.9% to 44.8%. Chronic viral hepatitis was identified as a risk factor for hepatic late adverse effects in univariate analyses. It is unclear which specific antineoplastic treatments increase the risk of hepatic late adverse effects

AUTHORS' CONCLUSIONS

The prevalence of hepatic late adverse effects ranged from 7.9% to 52.8% when selecting studies with an adequate outcome definition. It has not been established which childhood cancer treatments result in hepatic late adverse effects. There is a suggestion that chronic viral hepatitis increases the risk of hepatic late adverse effects. More well-designed studies are needed to reliably evaluate the prevalence of, and risk factors for, hepatic late adverse effects after antineoplastic treatment for childhood cancer.

The prevalence of molecular and immunologic infective markers of hepatitis viruses in patients with hematological malignancies

Acute and chronic viral hepatitis infections are corresponding to increase the risk of different types of hematological malignancies especially with leukemia. In this study the serological and molecular markers of hepatitis viruses were evaluated in patients with different types of leukemia in comparing with control group. In this cross sectional study, 100 EDTA-treated blood samples were collected from leukemia patients and also from healthy control group, respectively. Serological and molecular markers of HBV, HCV and HDV viruses were analyzed for determination of the role of these hepatitis viruses in clinical outcomes of leukemia disorders. Increasing risk factors of leukemia were evaluated statistically in two studied groups by SPSS software. One of molecular and immunological markers of HBV, HDV and HCV was found in 24 of 100 (24%), 22 of 100 (22%), and 1 of 100 (1%) patients with leukemia and in 12 of 100 (12%), 6 of 100 (6%), and 2 of 100 (2%) control patients. Significant differences were detected in detection of HBsAg (P = 0.02), HBeAb (P = 0.009), and HCV-RNA (P = 0.05) between leukemia patients and control group, respectively. The high prevalence of HBV and HCV infective markers were detected in ALL and AML patients. Identification of high prevalence of HBV and HCV infective markers in leukemia patients proposed strong association between hepatitis viral infections and leukemia. Therefore, evaluation of the prevalence of viral hepatitis infections in larger groups of patients with long lasting follow up is suggesting.

Outcome of combination antiviral therapy in chronic hepatitis C virus infection during therapy of acute lymphoblastic leukemia

Chronic hepatitis C virus (HCV) infection is not uncommon in patients with acute leukemia due to frequent blood transfusions. The treatment of HCV in patients with acute leukemia can produce profound immune dysfunction with the risk of severe cytopenia. We report the case of a young man who was treated with combined therapy of peginterferon α 2a and ribavirin for HCV while he was on maintenance anti-leukemic treatment. The patient required reduction in the dose of peginterferon α 2a and the addition of filgrastim due to neutropenia. Therapy for HCV was continued for 72 weeks and at the end of therapy, the patient had undetectable HCV RNA. The patient maintained a sustained viral response two years after the end of therapy and developed complete remission of leukemia, whereupon his anti-leukemic therapy was also discontinued. We recommend conducting further large prospective studies in HCV patients treated for leukemia to determine the safety and efficacy of antiviral therapy in this group of patients.

Hepatitis B and C virus infections in Turkish children with cancer

In this study, we tested 137 Turkish children with cancer (51 with acute leukemia, 48 with lymphoma, 38 with solid tumors) while they were undergoing chemotherapy, and a control group of 45 for evidence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections using the enzyme-linked immunosorbent assay (ELISA) and polymerase chain reaction (PCR). The control group included children with other disease who had applied to the outpatient clinic during the study period and had no history of jaundice or transfusion. Sixty-five (47.4%) patients with cancer and 7 (20%) children in the control group were positive for hepatitis B surface antigen (HBsAg) (p < 0.01). HBV DNA was detected in 59 (43.1%) patients and in 9 (20%) controls (p < 0.01). HCV specific antibody (anti-HCV) was detected in 8 (5.8%) patients and in 1 (2.2%) control (p > 0.05). Eight patients (5.8%) had circulating HCV RNA, but none had in the control group (p = 0.09). Ten (13.9%) of the 72 patients who were negative for HBsAg had circulating HBV DNA, and 7 (5.4%) of the 129 patients who were negative for anti-HCV had circulating HCV RNA. We concluded that HBV and HCV infections are common among Turkish children with cancer. In countries where HBV infection is widespread among the general population as in Turkey, children with cancer are under greater risk for HBV infection.