Risk factors for hepatitis B virus reactivation after conformal radiotherapy in patients with hepatocellular carcinoma

Time variation of high-risk groups for liver function deteriorations within fluctuating long-term liver function after hepatic radiotherapy in patients with hepatocellular carcinoma

PURPOSE

The purpose of this study is to find essential risk factors associated with liver function (LF) deteriorations within fluctuating long-term LF and their time-varying effects in patients with hepatocellular carcinoma (HCC) receiving hepatic radiotherapy and to identify high-risk groups for adverse LF deteriorations and their changes over time in facilitating the prevention of hepatic decompensation and the improvement of survival.

MATERIALS AND METHODS

A total of 133 HCC patients treated by hepatic radiotherapy were enrolled. A study design was conducted to convert posttreatment long-term LF with fluctuating levels over time to recurrent LF events using defined upgrades in a grading scale. The hazard ratios (HR) of pretreatment biochemical, demographic, clinical, and dosimetric factors in developing posttreatment LF events were estimated using the Cox model. Methodologies of the counting process approach, robust variance estimation, goodness-of-fit testing based on the Schoenfeld residuals, and time-dependent covariates in survival analysis were employed to handle the correlation within subjects and evaluate the time-varying effects during long-term follow-up.

RESULTS

Baseline LF score before radiotherapy and gender were significant factors. Initial HR in developing LF events was 1.17 (95% CI 1.11-1.23; P < 0.001) for each increase of baseline LF score and kept almost constant over time (HR, 1.00; 95% CI 1.00-1.01; P = 0.065). However, no difference was observed regarding initial hazards for gender (HR, 1.00; 95% CI 0.64-1.56; P = 0.994), but the hazard for women got higher monthly over time compared with men (HR, 1.04; 95% CI 1.01-1.07; P = 0.006).

CONCLUSIONS

High-risk groups for adverse LF deteriorations after hepatic radiotherapy may change over time. Patients with poor baseline LF are vulnerable from the beginning. Women require prevention strategies and careful monitoring for deteriorations at a later stage.

Selection of HBV key reactivation factors based on maximum information coefficient combined with cosine similarity

BACKGROUND

Hepatitis B Virus (HBV) reactivation is the most common complication for patients with primary liver cancer (PLC) after radiotherapy. How to reduce the reactivation of HBV has been a hot topic in the study of postoperative radiotherapy for liver cancer.

OBJECTIVE

To find out the inducement of HBV reactivation, a feature selection algorithm (MIC-CS) using maximum information coefficient (MIC) combined with cosine similarity (CS) was proposed to screen the risk factors that may affect HBV reactivation.

METHOD

Firstly, different factors were coded and MIC between patients was calculated to acquire the association between different factors and HBV reactivation. Secondly, a cosine similarity algorithm was constructed to calculate the similarity relationship between different factors, thus removing redundant information. Finally, combined with the weight of the two, the potential risk factors were sorted and the key factors leading to HBV reactivation were selected.

RESULTS

The results indicated that HBV baseline, external boundary, TNM, KPS score, VD, AFP, and Child-Pugh could lead to HBV reactivation after radiotherapy. The classification model was constructed for the above factors, with the highest classification accuracy of 84% and the AUC value of 0.71.

CONCLUSION

Comparing multiple feature selection methods, the results showed that the effect of the MIC-CS was significantly better than MIM, CMIM, and mRMR, so it has a very broad application prospect.

Correlation of HBV DNA and Hepatitis B Surface Antigen Levels With Tumor Response, Liver Function and Immunological Indicators in Liver Cancer Patients With HBV Infection Undergoing PD-1 Inhibition Combinational Therapy

Background

Thus far, few studies have investigated the safety and efficacy of programmed death-1 (PD-1) immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) antibodies in patients with hepatitis B virus (HBV)-related liver cancer.

Objective

To investigate the effect of combination therapy with programmed death-1 (PD-1) immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) on HBV-related liver cancer.

Methods

Until January 31, 2022, liver cancer patients with hepatitis B surface antigen (HBsAg) or HBV DNA positivity, treated with PD-1 ICIs and TKIs combined with nucleoside analogs (NAs), were retrospectively reviewed. The correlation between the change in HBV DNA and HBsAg levels and tumor response was analyzed using the χ² test. Cox univariate and multivariate survival analyses and Kaplan–Meier curves were used to identify and compare risk factors and overall survival (OS).

Results

A total of 48 patients were enrolled in the study, with an objective response rate (ORR) of 31.3%, a disease control rate (DCR) of 66.7%; the incidence of adverse events was mostly mild. A significant decrease in HBV DNA and HBsAg levels was observed at 12 and 24 weeks compared with the baseline (p < 0.05). Compared to patients with progressive disease (PD), patients with disease control showed a more significant decrease in HBV DNA and HBsAg levels at 12 and 24 weeks (p < 0.001). Eleven patients showed elevations in HBV DNA level and one of them showed HBV reactivation; however, the reactivation was not associated hepatitis. Moreover, eight patients showed elevation in HBsAg. Elevation in HBV DNA level was associated with poor tumor response (P=0.001, OR=18.643 [95% CI: 3.271–106.253]). Cox survival analysis suggested that HBV DNA increase (P=0.011, HR=4.816, 95% CI: 1.439–16.117) and HBsAg increase (P=0.022, HR=4.161, 95% CI: 1.224–16.144) were independent risk factors associated with survival time. Kaplan–Meier curves suggested that patients who exhibited an increase in HBV DNA (6.87 months vs undefined, log-rank test: p= 0.004) and HBsAg (8.07 months vs undefined, log-rank test: p= 0.004) levels had a shorter median survival time (MST). Patients without increased HBsAg showed better baseline liver function and routine blood tests (p<0.05) than patients with increased HBsAg. An increase in C-reactive protein (CRP) and interleukin-6 (IL-6), and a decrease in T lymphocytes, CD4+ T lymphocytes, and B lymphocytes at 1-week post-treatment associated with HBsAg well-controlled.

Conclusion

HBV-related liver cancer patients treated with combination therapy showed improved efficacy and safety profiles. Combination therapy has some effect on HBV infection, and a correlation between tumor response and antiviral efficacy was found. Elevation of HBV DNA and HBsAg levels may indicate poorer tumor response and survival time. Better baseline liver function and early immune activation may be associated with decline in HBsAg levels.

Risk of HBV reactivation during therapies for HCC: A systematic review

BACKGROUND AND AIMS

Treatment for HCC has evolved rapidly, but the risk of HBV reactivation to new therapies is unclear. We systematically reviewed data on HBV reactivation in patients receiving HCC therapy in relation to use of HBV antiviral prophylaxis.

APPROACH AND RESULTS

A literature search was performed to identify all published studies including HBsAg-positive patients with HCC providing data on HBV reactivation. Forty-one studies with 10,223 patients, all from Asia, were included. The pooled HBV reactivation rate was 5% in patients receiving no specific HCC therapy and was higher in patients undergoing surgical resection (16%), transarterial chemoembolization (19%), or radiotherapy (14%) and intermediate in patients treated with local ablation therapy (7%) or systemic agents (7%). HBV reactivation rates were higher in those without compared to those with HBV prophylaxis (ablation, 9% versus 0%; resection, 20% versus 3%; chemoembolization, 23% versus 1%; external radiotherapy alone, 18% versus 0%; systemic therapy, 9% versus 3%). HBV-related biochemical reactivation rates varied between 6%-11% and 2% in patients receiving HCC therapies with high and intermediate HBV reactivation risk, respectively. Liver decompensation and death were rarely reported (0%-3%) and only in patients receiving HCC treatment with high HBV reactivation risk.

CONCLUSIONS

HBsAg-positive patients with HCC are at high or intermediate risk of HBV reactivation depending on the type of HCC therapy. Nucleos(t)ide analogue prophylaxis reduces the risk of HBV reactivation, practically eliminates the risk of hepatitis flare, and should be administered regardless of HCC treatment.

Prediction of survival according to kinetic changes of cytokines and hepatitis status following radioembolization with yttrium-90 microspheres

BACKGROUND/PURPOSE

Yttrium-90 radioembolization (Y90-RE) may exert an immunomodulatory effect on the tumor microenvironment of hepatocellular carcinoma (HCC). Whether the host immune alterations after Y90-RE correlated with outcomes and whether Y90-RE affects viral hepatitis reactivation remains unclear.

METHODS

Between July 2014 and July 2015, 18 patients undergoing Y90-RE for HCC were prospectively enrolled. Serum levels of virological markers, cytokines and chemokines were measured at baseline, 2, 4, and 12 weeks after Y90-RE. Factors associated with the clinical outcomes were evaluated.

RESULTS

The disease control rate of Y90-RE was 44.4% (8 of 18) at 12 weeks, including 1 case with complete response, 4 cases with partial response, and 3 cases with stable disease. Significant elevation from baseline to week 2 and week 4 were noted in IL-10 level (8.4 ± 33.8, 15.7 ± 31.6, and 16.0 ± 41.7 pg/mL, P = 0.041 and 0.013, respectively) and IP-10 level (113.5 ± 97.8, 189.1 ± 164.4, and 168.6 ± 150.5 pg/mL, P = 0.027 and 0.026, respectively). After Y90-RE, transient HBV reactivation occurred in 2 patients, and 1 out of 3 HCV-infected patients exhibited HCV reactivation. Univariate analysis revealed that lower baseline IP-10 (≤200 pg/mL) and alanine aminotransferase (ALT) (≤50 U/L) levels were associated with better overall survival. Multivariate analysis identified an IP-10 level of 200 pg/mL (HR = 4.374, P = 0.045) as a predictor of overall survival.

CONCLUSION

Baseline serum IP-10 level is a predictor of survival for HCC patients undergoing Y90-RE. HBV and HCV reactivation may develop after Y90-RE treatment.

Analysis of Hepatitis B Virus Reactivation After Radiotherapy in Patients With Hepatocellular Carcinoma Using the Lyman NTCP Model

Purpose:

To analyze the correlation of hepatitis B virus reactivation with patient-related and treatment-related dose–volume factors and to describe the feasibility of hepatitis B virus reactivation analyzed by a normal tissue complication probability model for patients with hepatocellular carcinoma treated with radiotherapy.

Materials and Methods:

Ninety patients with hepatitis B virus-related hepatocellular carcinoma treated with radiotherapy were enrolled in this retrospective study and were followed from June 2009 to December 2015. Of the 90 patients, 78 had received conventional fractionation radiotherapy to a mean dose of 39.6 to 50.4 Gy and 12 patients were scheduled to receive hypofractionation. The physical doses were converted into 2 Gy equivalents for analysis. The parameters, TD₅₀ (1), n, and m, of the Lyman-Kutcher-Burman normal tissue complication probability model were derived using maximum likelihood estimation. Bootstrap and leave-one-out were employed to against model overfitting and improve the model stability.

Results:

Radiation-induced liver diseases were 17.8%, hepatitis B virus reactivation was 22.2%, and hepatitis B virus reactivation-induced hepatitis was 21.1%, respectively. In multivariate analysis, the V_5Gy was associated with hepatitis B virus reactivation; TD₅₀ (1), m, and n were 32.3, 0.55, and 0.71 Gy, respectively, for hepatitis B virus reactivation. Bootstrap and leave-one-out results showed that the hepatitis B virus parameter fits were extremely robust.

Conclusion:

A Lyman-Kutcher-Burman normal tissue complication probability model has been established to predict hepatitis B virus reactivation for patients with hepatocellular carcinoma who received radiotherapy.

Infection Load and Prevalence of Novel Viruses Identified from the Bank Vole Do Not Associate with Exposure to Environmental Radioactivity

Bank voles (Myodes glareolus) are host to many zoonotic viruses. As bank voles inhabiting areas contaminated by radionuclides show signs of immunosuppression, resistance to apoptosis, and elevated DNA repair activity, we predicted an association between virome composition and exposure to radionuclides. To test this hypothesis, we studied the bank vole virome in samples of plasma derived from animals inhabiting areas of Ukraine (contaminated areas surrounding the former nuclear power plant at Chernobyl, and uncontaminated areas close to Kyiv) that differed in level of environmental radiation contamination. We discovered four strains of hepacivirus and four new virus sequences: two adeno-associated viruses, an arterivirus, and a mosavirus. However, viral prevalence and viral load, and the ability to cause a systemic infection, was not dependent on the level of environmental radiation.

Phase I/II trial of helical IMRT-based stereotactic body radiotherapy for hepatocellular carcinoma

BACKGROUND

To report the results of a phase I/II study of helical IMRT-based stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC).

METHODS

Eligibility included Child-Turcotte-Pugh class A or B, ≤3 lesions, and cumulative tumor diameter ≤6 cm. Dose was escalated from 36 Gy to 60 Gy delivered in 4 fractions. Grade ≥3 gastrointestinal toxicities (CTCAE v3.0) or radiation-induced liver disease defined dose-limiting toxicity (DLT).

RESULTS

Thirty-two patients were enrolled: seven in dose levels 1-2 (36-44 Gy) and 25 in levels 3-4 (42-60 Gy). Failures included 1 local, 14 outfield intrahepatic, 2 distant, 1 concurrent local and outfield, 1 concurrent outfield and distant, and 1 concurrent local, outfield, and distant. Nine had grade 3 hematologic toxicities and 5 had grade 2 hepatic toxicities; no patient experienced DLT. Two-year local control (LFFS), outfield intrahepatic control (OutFFS), and overall survival (OS) rates were 80.9%, 46.7%, and 81.3%, respectively. Dose levels 3-4 and pre-radiotherapy multi-segment recurrence were independent prognostic factors for LFFS and OutFFS, respectively. Two-year LFFS, OutFFS, and OS were significantly higher for patients who were treated with dose-levels 3/4 for tumor(s) involving single segment compared with the rest of the patients.

CONCLUSIONS

Helical IMRT-based SBRT was safe and effective, and patients with multi-segment recurrences prior to SBRT need to be closely followed.

Hepatitis B Virus Reactivation in a Patient with Nonalcoholic Steatohepatitis 41 Months after Rituximab-containing Chemotherapy

Hepatitis B virus (HBV) reactivation occasionally occurs long after immunosuppressive therapy. The characteristics of late HBV reactivation remain unclear. We herein present a case of HBV reactivation in a patient with nonalcoholic steatohepatitis (NASH) more than 3 years after rituximab-containing chemotherapy for diffuse large B-cell lymphoma. Increased transaminase levels, which were induced by NASH, were observed after chemotherapy and were alleviated with statin treatment. HBV reactivation was identified incidentally. The patient developed hepatitis that improved with entecavir therapy. Our case might indicate that the presence of NASH is associated with HBV reactivation long after treatment and that statins, as immune-modulatory agents, affect HBV reactivation.

Antiviral Therapy for AECHB and Severe Hepatitis B (Liver Failure)

This chapter describes the principles of antiviral therapy, treatment strategies, medications and recommendations for AECHB, HBV-ACLF, HBV-related liver cirrhosis, HBV-related HCC, and liver transplantation.

Severe exacerbation of chronic hepatitis B is closely related to continuous HBV replication. Therefore, inhibiting HBV replication to reduce viral load may block disease progression and improve the quality of life of these patients. ETV or TDF has been recommend first-line drug for the treatment of AECHB.

A hyperactive immune response due to continuous HBV replication is the main mechanism for development of severe hepatitis B. In addition to comprehensive treatment, early administration of potent nucleoside analogs can rapidly reduce HBV DNA concentration, relieve immune injury induced by HBV, and reduce liver inflammation and patient mortality. Antiviral agents have become important in the treatment of severe exacerbation of chronic hepatitis B.

Long-term antiviral treatment with nucleoside analogs can delay or reverse the progress of liver cirrhosis. Virologic response, viral resistance and adverse drug reactions should be closely monitored during treatment. The treatment should be optimized for maximum effect based on each patient’s responses.

Effective antiviral therapy can suppress HBV replication and reduce the incidence of HBV-related HCC. Patients with HBV-related HCC should receive individualized and optimal multidisciplinary comprehensive treatment. Anti-viral drugs with high efficacy, low resistance and low adverse drug reactions should be selected to improve the patient’s quality of life and prolong survival time.

Methods to prevent HBV reinfection after liver transplantation include passive immunization (HBIG), antiviral treatment (nucleoside analogs) and active immunization (hepatitis B vaccine).

Clinical trials involving sequential combination therapy with NUC and Peg-IFN have shown statistically significant decline in HBsAg levels on treatment and high rates of sustained post-treatment serologic response. Combination therapy with novel DAA and immunotherapeutic approach may hold promise to overcome both cccDNA persistence and immune escape, representing a critical step towards HBV cure.

Radiation Exposure and Bell's Palsy: A Hypothetical Association

Bell's palsy is an idiopathic peripheral nerve palsy involving the facial nerve. It accounts for 60 to 75% of all cases of unilateral facial paralysis. The main mechanisms to induce BP remain unclear, but infection, ischemic condition and immunodeficiency may contribute to the development of Bell's palsy. Accumulating evidence has shown several factors can trigger the reactivation of latent HSV including psychological stressors, physical stressors and immunosuppression. Ionization and non-ionization radiations are of importance of physical stressors. Some data have shown radiation can reactivate HSVs. Based on preliminary studies showing radiation reactivation of HSVs, we aimed to hypothesize radiation (in both forms of ionization and non-ionization) may cause Bell's palsy. In the future, the role of radiotherapy, radiofrequency radiation from mobile phones and wireless devices in HSV reactivation and Bell's palsy should be investigated.

Hepatitis B virus reactivation after radiotherapy for hepatocellular carcinoma and efficacy of antiviral treatment: A multicenter study

Convincing data that support routine use of preventive therapy against hepatitis B virus (HBV) reactivation in radiotherapy (RT) for hepatocellular carcinoma (HCC) are lacking. The aim of this study was to investigate the incidence, clinical significance, and risk factors of HBV reactivation after RT. Medical records of 133 HBsAg (+) HCC patients who received radiotherapy from March 2009 to February 2016 were reviewed. Patients were divided into two groups: 1) non-antiviral group, those who did not receive antiviral therapy before RT (n = 27); and antiviral group (those who underwent antiviral therapy before RT) (n = 106). Factors related to HBV reactivation in HCC patients were evaluated. 17 (12.7%) of 133 patients developed HBV reactivation after RT. Patients in the antiviral group had significantly lower rates of HBV reactivation than those in the non-antiviral group (7.5% vs. 33.3%, p<0.001). HBV related hepatitis was also lower in the antiviral group (3.8% vs. 14.8%, p = 0.031). In multivariate analysis, absence of antiviral treatment (OR: 8.339, 95% CI: 2.532-27.470, p<0.001) and combined treatment of RT with transarterial chemoembolizatoin (TACE) (OR: 5.313, 95% CI: 1.548-18.232, p = 0.008) were risk factors for HBV reactivation. HBV reactivation can occur after radiotherapy. Combination treatment of RT with TACE and non-antiviral treatment are major risk factors for HBV reactivation during or after RT. Therefore, preventive antiviral therapy should be recommended for patients with HCC who are scheduled to receive RT.

Strategies for prediction and mitigation of radiation-induced liver toxicity

Although well described in the 1960s, liver toxicity secondary to radiation therapy, commonly known as radiation-induced liver disease (RILD), remains a major challenge. RILD encompasses two distinct clinical entities, a 'classic' form, composed of anicteric hepatomegaly, ascites and elevated alkaline phosphatase; and a 'non-classic' form, with liver transaminases elevated to more than five times the reference value, or worsening of liver metabolic function represented as an increase of 2 or more points in the Child-Pugh score classification. The risk of occurrence of RILD has historically limited the applicability of radiation for the treatment of liver malignancies. With the development of 3D conformal radiation therapy, which allowed for partial organ irradiation based on computed tomography treatment planning, there has been a resurgence of interest in the use of liver irradiation. Since then, a large body of evidence regarding the liver tolerance to conventionally fractionated radiation has been produced, but severe liver toxicities has continued to be reported. More recently, improvements in diagnostic imaging, radiation treatment planning technology and delivery systems have prompted the development of stereotactic body radiotherapy (SBRT), by which high doses of radiation can be delivered with high target accuracy and a steep dose gradient at the tumor - normal tissue interface, offering an opportunity of decreasing toxicity rates while improving tumor control. Here, we present an overview of the role SBRT has played in the management of liver tumors, addressing the challenges and opportunities to reduce the incidence of RILD, such as adaptive approaches and machine-learning-based predictive models.

Effects of antiviral therapy on post-hepatectomy HBV reactivation and liver function in HBV DNA-negative patients with HBV-related hepatocellular carcinoma

The ability of antiviral therapy to reduce risk of post-hepatectomy hepatitis B virus (HBV) reactivation in patients negative for viral DNA is unclear. This prospective study involved 174 consecutive patients with hepatitis B virus related hepatocellular carcinoma who were negative for hepatitis B virus DNA in serum and who underwent hepatic resection. Hepatitis B virus reactivation occurred in 30 patients in the non-antiviral group (27.8%) but in only 2 patients in the antiviral group (3.0%, P < 0.001). Based on multivariate analysis, risk of hepatitis B virus reactivation was associated with minor hepatectomy and absence of antiviral therapy. Liver function indicators at one week after resection did not differ significantly between the two groups, or between patients who experienced hepatitis B virus reactivation or not. Nevertheless, alanine aminotransferase and albumin at 1 month after resection were significantly higher in the antiviral group than in the non-antiviral group, and they were significantly higher in patients who did not experience hepatitis B virus reactivation than in those who did. Therefore, patients with hepatitis B virus related hepatocellular carcinoma face substantial risk of hepatitis B virus reactivation after hepatectomy, even if they are negative for viral DNA at baseline. Antiviral therapy can reduce the risk of reactivation, helping improve liver function after surgery. (Clinicaltrials.gov registration number: NCT02829359).

Perioperative entecavir for patients with HBV-related hepatocellular carcinoma and low levels of viral DNA: analysis using propensity score matching

The safety and efficacy of perioperative antiviral therapy for patients with hepatitis B virus related hepatocellular carcinoma and low serum levels of hepatitis B virus DNA are unknown. This retrospective study compared serum levels of hepatitis B virus DNA, liver function, morbidity, and length of hospital stay between patients who underwent hepatic resection alone and patients who received entecavir therapy before and after resection (n = 44 in each group). Propensity score matching was used to reduce confounding due to baseline differences between the groups. Hepatitis B virus reactivation during follow-up, which lasted a median of 6.1 months, occurred in one patient in the entecavir group (2.3%) and 11 patients in the resection-only group (25%; P = 0.02). Liver function, especially alanine aminotransferase levels, recovered much faster in the entecavir group. This group also showed a slightly lower rate of morbidity (P = 0.081) as well as significantly shorter overall hospital stay (20.1 ± 4.9 vs 24.9 ± 13.2 days; P = 0.028) and postoperative hospital stay (11.4 ± 1.9 vs 16.8 ± 13.1 days; P = 0.008). These results from this pilot study suggest that patients with hepatitis B virus related hepatocellular carcinoma and low levels of hepatitis B virus DNA are at risk of hepatitis B virus reactivation following resection, and that perioperative entecavir therapy can safely and effectively reduce this risk. Such therapy also appears to improve liver function and shorten hospitalization.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2016

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2016 was held in Montreal, Quebec, 5-7 February. Experts in radiation oncology, medical oncology, surgical oncology, and infectious diseases involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics: ■ Follow-up and survivorship of patients with resected colorectal cancer■ Indications for liver metastasectomy■ Treatment of oligometastases by stereotactic body radiation therapy■ Treatment of borderline resectable and unresectable pancreatic cancer■ Transarterial chemoembolization in hepatocellular carcinoma■ Infectious complications of antineoplastic agents.

HBV reactivation risk factors in patients with chronic HBV infection with low replicative state and resolved HBV infection undergoing hematopoietic stem cell transplantation in Korea

PURPOSE

To elucidate the rate and risk factors of HBV reactivation in patients with chronic HBV infection with low replicative state and resolved HBV infection undergoing allogenic/autologous hematopoietic stem-cell transplantation (HSCT) in Korea.

METHODS

The medical charts of 506 patients who underwent allogenic/autologous HSCT from January 2008 to December 2013 were analyzed retrospectively. We examined the reactivation rate and variables related to the risk of HBV reactivation, with a median follow-up period of 41.8 (1-245) months. Univariate analysis was used to identify any factors associated with HBV reactivation. Factors that were significant in the univariate analysis were entered into a stepwise multivariate analysis to find the most significant risk factors associated with HBV reactivation.

RESULTS

The reactivation rate of HBV in patients who underwent HSCT was 4.2 % (21/506). In subgroup analysis, the HBV reactivation rate (14.3 %) was the highest among HBsAg(+) patients (5/35). The reactivation rate of HBV in patients with resolved HBV infection [HBsAg(-)/HBcAb(+) with or without anti-HBs antibody] was 5.9 % (10/171). In univariate analysis for risk factors of HBV reactivation in patients who underwent HSCT, initial detectable HBV DNA (p = 0.004), age (≥60 years) (p = 0.012), recipient hepatitis B surface antigen-positive (HbsAg)(+) before HSCT (p = 0.004), recipient hepatitis B surface antibody-negative (HBsAb)(-) before HSCT (p = 0.005), recipient hepatitis B core antibody-positive (HbcAb)(+) before HSCT (p = 0.013), and donor HBsAg(+) (p < 0.001) were associated with reactivation of HBV. In multivariate analysis, significant risk factors of HBV reactivation in patients who underwent HSCT were old age (≥60 years) (p = 0.032) and donor HBsAg(+) (p = 0.026).

CONCLUSION

Old age (≥60 years) and donor HBsAg(+) were risk factors for HBV reactivation in HSCT patients. Preemptive antiviral treatment should be considered in these patients.

Management of hepatitis B reactivation in immunosuppressed patients: An update on current recommendations

The proportion of hepatitis B virus (HBV) previously exposed patients who receive immunosuppressive treatment is usually very small. However, if these individuals are exposed to potent immunosuppressive compounds, the risk of HBV reactivation (HBVr) increases with the presence of hepatitis B surface antigen (HBsAg) in the serum. Chronic HBsAg carriers have a higher risk than those who have a total IgG anticore as the only marker of resolved/occult HBV disease. The loss of immune control in these patients may results in the reactivation of HBV replication within hepatocytes. Upon reconstitution of the immune system, infected hepatocytes are once again targeted and damaged by immune surveillance in an effort to clear the virus. There are different virological scenarios, and a wide spectrum of associated drugs with specific and stratified risk for the development of HBVr. Some of this agents can trigger a severe degree of hepatocellular damage, including hepatitis, acute liver failure, and even death despite employment of effective antiviral therapies. Currently, HBVr incidence seems to be increasing around the world; a fact mainly related to the incessant appearance of more powerful immunosuppressive drugs launched to the market. Moreover, there is no consensus on the length of prophylactic treatment before the patients are treated with immunosuppressive therapy, and for how long this therapy should be extended once treatment is completed. Therefore, this review article will focus on when to treat, when to monitor, what patients should receive HBV therapy, and what drugs should be selected for each scenario. Lastly, we will update the definition, risk factors, screening, and treatment recommendations based on both current and different HBV management guidelines.

How have the recent advances in antiviral therapy impacted the management of virus-related hepatocellular carcinoma?

INTRODUCTION

Whether the recent advances in antiviral therapy including nucleos(t)ide analogue (NA) or interferon (IFN) impacts the management of patients with virus-related hepatocellular carcinoma (HCC) remains unclear.

AREA COVERED

The beneficial effects of antiviral therapy on HCC patients receiving curative treatment, transhepatic arterial chemoembolization (TACE), or radiotherapy are reviewed and discussed.

EXPERT OPINION

For patients with HCV-related HCC after curative treatment, interferon (IFN)-based therapy has been shown to improve the survival and reduces the risk of HCC recurrence. However, it carries the risk of adverse effects, especially in cirrhotic patients. Therefore, the benefit of IFN should be weighted against its risk in each individual. For patients with HBV-related HCC after curative treatments, antiviral treatment with NA has been found to improve liver function, overall survival, and possibly reduce the risk of HCC recurrence. In contrast, these benefits were not consistently observed in those receiving IFN treatment. In HCC patients receiving palliative TACE or radiotherapy, HBV reactivation occurs in a small proportion of them, and preemptive NA treatment can reduce the risk of hepatitis flare due to viral reactivation. Therefore, NA treatment after curative treatments or TACE is strongly recommended for HCC patients with high viral load (HBV DNA> 2000 IU/mL).

Radiation-induced hepatitis B virus reactivation in hepatocellular carcinoma: A case report

Hepatitis B virus (HBV) reactivation associated with radiotherapy is rare. The present study reports the case of a 46-year-old man that experienced fatal HBV reactivation. The patient suffered from hepatocellular carcinoma (HCC) with portal vein tumor thrombus, which was treated by radiotherapy at a daily fraction of 2 Gy over 5 weeks, up to a total radiation dose of ~50 Gy. The patient presented with fatigue, yellow sclera and abdominal distension ~8 weeks subsequent to the administration of radiotherapy. The liver function tests, including the level of total bilirubin and prothrombin time, suggested acute-on-chronic liver failure. The serum HBV-DNA level had also increased between undetectable levels and 7.2×10⁴ copies/ml. Although the present patient with HCC was treated with 0.5 mg/day entecavir for 8 weeks, in addition to radiotherapy, radiation-induced HBV reactivation occurred. The condition of the patient worsened gradually. The present study emphasizes the importance of liver function and HBV-DNA screening and pre-emptive antiviral prophylaxis prior to radiotherapy in patients with HCC.

Stereotactic body radiation therapy in hepatocellular carcinoma: Optimal treatment strategies based on liver segmentation and functional hepatic reserve

AIM

To discuss current dosage for stereotactic body radiation therapy (SBRT) in hepatocellular carcinoma (HCC) patients and suggest alternative treatment strategies according to liver segmentation as defined by the Couinaud classification.

BACKGROUND

SBRT is a safe and effective alternative treatment for HCC patients who are unable to undergo liver ablation/resection. However, the SBRT fractionation schemes and treatment planning strategies are not well established.

MATERIALS AND METHODS

In this article, the latest developments and key findings from research studies exploring the efficacy of SBRT fractionation schemes for treatment of HCC are reviewed. Patients' characteristics, fractionation schemes, treatment outcomes and toxicities were compiled. Special attention was focused on SBRT fractionation approaches that take into consideration liver segmentation according to the Couinaud classification and functional hepatic reserve based on Child-Pugh (CP) liver cirrhosis classification.

RESULTS

The most common SBRT fractionation schemes for HCC were 3 × 10-20 Gy, 4-6 × 8-10 Gy, and 10 × 5-5.5 Gy. Based on previous SBRT studies, and in consideration of tumor size and CP classification, we proposed 3 × 15-25 Gy for patients with tumor size <3 cm and adequate liver reserve (CP-A score 5), 5 × 10-12 Gy for patients with tumor sizes between 3 and 5 cm or inadequate liver reserve (CP-A score 6), and 10 × 5-5.5 Gy for patients with tumor size >5 cm or CP-B score.

CONCLUSIONS

Treatment schemes in SBRT for HCC vary according to liver segmentation and functional hepatic reserve. Further prospective studies may be necessary to identify the optimal dose of SBRT for HCC.