Viral elimination is essential for improving surgical outcomes of hepatitis C virus-related hepatocellular carcinoma: Multicenter retrospective analysis

AIM

The impact of sustained virologic response (SVR) on surgical outcomes for patients with hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) remains controversial. This study aimed to evaluate the influence of SVR on long-term surgical outcomes after hepatectomy.

METHODS

This multicenter study included 504 patients who underwent curative resection for HCV-related HCC. Patients with a history of HCC treatment, HBV infection, poor liver function, and tumor with major vascular invasion were excluded. Long-term surgical outcomes (overall survival [OS] and recurrence-free survival [RFS]) among patients who achieved SVR before hepatectomy (Pre-SVR group: 58 patients), after hepatectomy (Post-SVR group: 54 patients), and without SVR (Non-SVR group: 186 patients) were compared after adjusting for 13 confounding factors. Using the surgically resected specimens, comparison of the pathological changes in liver fibrosis between the first and second hepatectomy were analyzed.

RESULTS

Patients with SVR were younger, had better liver function, and less liver fibrosis compared to patients without SVR. Propensity score-matched OS and RFS were significantly better in Pre-SVR group than Non-SVR group (P = .029 and P = .009, respectively). Inverse probability-weighted OS and RFS were also significantly better in the Post-SVR group (P = .001 and P = .021, respectively) than in the Non-SVR group. Histopathological evaluation revealed that only the patients with SVR had regression of liver fibrosis (P < .05).

CONCLUSION

Achievement of SVR before or after hepatectomy is essential for improving long-term surgical outcomes in patients with HCV-related HCC.

Long-term outcome of hepatocellular carcinoma occurrence, esophageal varices exacerbation, and mortality in hepatitis C virus-related liver cirrhosis after interferon-based therapy

AIM

The long-term effects of sustained virologic response (SVR) to antiviral therapy on the risk of liver complications, such as exacerbation of esophageal varices (EV), hepatocellular carcinoma (HCC), malignant lymphoma, and liver-related and overall death in hepatitis C virus (HCV)-infected patients with liver cirrhosis are not fully known.

METHODS

These risks were evaluated during long-term follow up of 457 patients with HCV-related Child-Pugh Class A liver cirrhosis without history of HCC.

RESULTS

The respective cumulative 5- and 10-year rates of EV exacerbation were 2.0% and 3.1%. Multivariate analysis identified the presence of EVs, thrombocytopenia at baseline. and alcohol intake as significant independent predictors of EV exacerbation before and after SVR. The cumulative 5- and 10-year rates of HCC were 6.8% and 10.2%, respectively. Male sex and the presence of EV were significant independent determinants of HCC before and after SVR. Although the cumulative 5-year HCC recurrence rate was 49.4%, the overall survival rate since HCC was 73.6% at 5 years. The overall survival rates since SVR were 98.7% and 93.6% at 5 and 10 years, respectively. Progression of HCC was the most frequent all-cause mortality, but none of the patients died of liver decompensation. Male sex and Fibrosis-4 index of ≥3.0 after SVR were significant and independent predictors of mortality.

CONCLUSION

Patients with HCV remain at risk of HCC for >10 years after achieving SVR, and HCC is the most common cause of mortality. We recommend long-term surveillance of cirrhotic patients with HCV, even after achieving SVR.

Molecular Mechanisms of Hepatocarcinogenesis Following Sustained Virological Response in Patients with Chronic Hepatitis C Virus Infection

Despite the success of direct-acting antiviral (DAA) agents in treating chronic hepatitis C virus (HCV) infection, the number of cases of HCV-related hepatocellular carcinoma (HCC) is expected to increase over the next five years. HCC develops over the span of decades and is closely associated with fibrosis stage. HCV both directly and indirectly establishes a pro-inflammatory environment favorable for viral replication. Repeated cycles of cell death and regeneration lead to genomic instability and loss of cell cycle control. DAA therapy offers >90% sustained virological response (SVR) rates with fewer side effects and restrictions than interferon. While elimination of HCV helps to restore liver function and reverse mild fibrosis, post-SVR patients remain at elevated risk of HCC. A series of studies reporting higher than expected rates of HCC development among DAA-treated patients ignited debate over whether use of DAAs elevates HCC risk compared to interferon. However, recent prospective and retrospective studies based on larger patient cohorts have found no significant difference in risk between DAA and interferon therapy once other factors are taken into account. Although many mechanisms and pathways involved in hepatocarcinogenesis have been elucidated, our understanding of drivers specific to post-SVR hepatocarcinogenesis is still limited, and lack of suitable in vivo and in vitro experimental systems has hampered efforts to examine etiology-specific mechanisms that might serve to answer this question more thoroughly. Further research is needed to identify risk factors and biomarkers for post-SVR HCC and to develop targeted therapies based on more complete understanding of the molecules and pathways implicated in hepatocarcinogenesis.

Determinants of survival following hepatocellular carcinoma in Egyptian patients with untreated chronic HCV infection in the pre-DAA era

BACKGROUND AND STUDY AIMS

In this study we assessed rates and determinants of survival in people with untreated chronic HCV infection and hepatocellular carcinoma (HCC) in an Egyptian liver clinic setting.

PATIENTS AND METHODS

This is a prospective cohort study of patients diagnosed with HCV-related HCC and undergoing HCC management at a national liver centre in Egypt in 2013-2014 and with a follow-up through 2016.

RESULTS

A total of 345 patients diagnosed with HCV-related liver cirrhosis complicated by HCC were included. Median age at diagnosis was 57 years (IQR = 52, 62), the majority were male (78%) and Child-Turcotte-Pugh (CTP) class A (64%). At diagnosis Barcelona Clinic Liver Cancer staging (BCLC) was 0 (8%), A (48%), B (20%), C (17%), and D (7%). Most common HCC management modalities were transarterial chemoembolization (TACE) (42%), and radiofrequency ablation (RFA) (21%). Median survival following HCC was 22.8 months. Factors associated with poorer survival in adjusted analyses were INR (HR = 1.81, p = 0.01), alpha-foeto protein (AFP) ≥200 (HR = 1.41, p = 0.02), higher CTP score (HR = 2.48, p < 0.01), and advanced BCLC stage (HR = 1.85, p < 0.01). One year survival in patients with CTP A, B, and C was 85%, 71% and 32%, respectively. One year survival following RFA, TACE, combination RFA/TACE, and sorafenib was 93%, 79%, 80% and 60%, respectively.

CONCLUSION

Survival following HCV-HCC in Egyptian patients undergoing HCC management in a specialised clinic setting is poor, although similar to high income country settings. CTP score is a key determinant of survival, even following adjustment for BCLC stage and HCC management.

Hepatocellular carcinoma risk following direct-acting antiviral HCV therapy: A systematic review, meta-analyses, and meta-regression

BACKGROUND & AIMS

The risk of hepatocellular carcinoma (HCC) occurrence or recurrence following direct-acting antiviral (DAA) hepatitis C virus (HCV) therapy remains unclear. The aims of this study were to compare the rate of HCC occurrence in patients with HCV-related cirrhosis, following DAA vs. interferon (IFN)-based cure, and to compare the rate of HCC recurrence in patients who received curative HCC treatment, following DAA vs. IFN-based cure.

METHODS

A search was conducted for reports published between January 2000 and February 2017. Studies were included if they assessed HCC outcomes by type and response to HCV therapy. Random-effects meta-analyses were undertaken to determine a combined estimate of HCC incidence rate per 100/person-years (py) among patients with a sustained virological response (SVR).

RESULTS

A total of 41 studies (n=13,875 patients), including 26 on HCC occurrence (IFN=17, DAA=9; prospective=19, retrospective=5, retrospective-prospective=2), and 17 on HCC recurrence (IFN=7, DAA=10; prospective=11, retrospective=5 and retrospective-prospective=1) were included. In studies assessing HCC occurrence, average follow-up was shorter (1.0 vs. 5.5years), and average age older (60 vs. 52years) in DAA studies. In studies assessing HCC recurrence, average follow-up was shorter (1.3 vs. 5.0years), but average age similar (64 vs. 66years) in DAA studies. HCC occurrence was 1.14/100 py (95% CI 0.86-1.52) and 2.96/100 py (95% CI 1.76-4.96) in IFN and DAA studies respectively. HCC recurrence was 9.21/100 py (95% CI 7.18-11.81) and 12.16/100 py (95% CI 5.00-29.58) in IFN and DAA studies respectively. In meta-regression adjusting for study follow-up and age, DAA therapy was not associated with higher HCC occurrence (RR 0.68; 95% CI 0.18-2.55; p=0.55) or recurrence (RR 0.62, 95% CI 0.11-3.45, p=0.56).

CONCLUSION

There is no evidence for differential HCC occurrence or recurrence risk following SVR from DAA and IFN-based therapy.

LAY SUMMARY

The risk of hepatocellular carcinoma (HCC) occurrence or recurrence following direct-acting antiviral (DAA) hepatitis C virus (HCV) therapy remains unclear. We conducted a meta-analysis to compare occurrence and recurrence of HCC in patients receiving either DAA or interferon (IFN) therapy. There is no evidence that HCC occurrence or recurrence is different between patients receiving DAA or IFN therapy.

Direct-Acting Antivirals Decreased Tumor Recurrence After Initial Treatment of Hepatitis C Virus-Related Hepatocellular Carcinoma

BACKGROUND

Suppressive activity of recurrence by interferon-free direct-acting antivirals (DAA) is not elucidated after curative treatment of hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

A total of 177 patients received DAA after curative manners of HCC: 89 patients underwent DAA therapy after initial HCC treatment, and the other 88 patients after repeated therapy of 2-10 times. Among a cohort of HCC patients with surgery and radiofrequency ablation, 89 patients were chosen adjusting age, gender, and Barcelona Clinic Liver Cancer (BCLC) staging with 89 patients with initial HCC therapy.

RESULTS

HCC recurrence rates at the end of first and second year were 18.1 and 22.1% in patients with once of HCC therapy, 28.2 and 41.6% in those with 2-3 times of therapy, and 60.2 and 74.5% in those with 4 or more times of therapy, respectively (P < 0.0001). Recurrence rates were compared between 89 patients with DAA therapy after initial HCC therapy and 89 age-, gender-, and BCLC staging-matched patients without antiviral therapy after initial HCC therapy. HCC recurrence rates at first and second year were 18.1 and 25.0% in patients with DAA therapy and 21.8 and 46.5% in those without DAA therapy, respectively (P = 0.003). Multivariate analysis showed DAA therapy significantly decreased recurrence rate with a hazard ratio of 0.353 (confidence interval: 0.191-0.651) after adjustment with covariates of tumor multiplicity, alpha-fetoprotein value, and prothrombin time.

CONCLUSIONS

DAA therapy significantly decreased recurrence rate when it was performed after initial HCC therapy.

Viral hepatitis and hepatocellular carcinoma: etiology and management

Chronic hepatitis B virus (HBV) and chronic hepatitis C virus (HCV) are associated with hepatic fibrosis and development of hepatocellular carcinoma (HCC). There are differences and variation with the incidence of HCC worldwide. Additionally, HCC develops via different pathways with these viral hepatitides. This review outlines the various mechanisms and pathophysiology that contributes to this process. There will also be a review on the recommended screening for HCC. Treatment considerations, which are different for these viruses, will be outlined in this review.

Hepatitis C-related hepatocellular carcinoma in the era of new generation antivirals

Hepatitis C virus infection is a major cause of hepatocellular carcinoma worldwide. Interferon has been the major antiviral treatment, yielding viral clearance in approximately half of patients. New direct-acting antivirals substantially improved the cure rate to above 90%. However, access to therapies remains limited due to the high costs and under-diagnosis of infection in specific subpopulations, e.g., baby boomers, inmates, and injection drug users, and therefore, hepatocellular carcinoma incidence is predicted to increase in the next decades even in high-resource countries. Moreover, cancer risk persists even after 10 years of viral cure, and thus a clinical strategy for its monitoring is urgently needed. Several risk-predictive host factors, e.g., advanced liver fibrosis, older age, accompanying metabolic diseases such as diabetes, persisting hepatic inflammation, and elevated alpha-fetoprotein, as well as viral factors, e.g., core protein variants and genotype 3, have been reported. Indeed, a molecular signature in the liver has been associated with cancer risk even after viral cure. Direct-acting antivirals may affect cancer development and recurrence, which needs to be determined in further investigation.