Serum fibrosis index-based risk score predicts hepatocellular carcinoma in untreated patients with chronic hepatitis B

Prediction model of hepatitis B virus-related hepatocellular carcinoma in patients receiving antiviral therapy

Chronic hepatitis B virus (HBV) infection, which ultimately leads to liver cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC), remains a significant disease burden worldwide. Despite the use of antiviral therapy (AVT) using oral nucleos(t)ide analogs (NUCs) with high genetic barriers, the risk of HCC development cannot be completely eliminated. Therefore, bi-annual surveillance of HCC using abdominal ultrasonography with or without tumor markers is recommended for at-risk populations. For a more precise assessment of future HCC risk at the individual level, many HCC prediction models have been proposed in the era of potent AVT with promising results. It allows prognostication according to the risk of HCC development, for example, low-vs. intermediate-vs. high-risk groups. Most of these models have the advantage of high negative predictive values for HCC development, allowing exemption from biannual HCC screening. Recently, non-invasive surrogate markers for liver fibrosis, such as vibration-controlled transient elastography, have been introduced as integral components of the equations, providing better predictive performance in general. Furthermore, beyond the conventional statistical methods that primarily depend on multi-variable Cox regression analyses based on the previous literature, newer techniques using artificial intelligence have also been applied in the design of HCC prediction models. Here, we aimed to review the HCC risk prediction models that were developed in the era of potent AVT and validated among independent cohorts to address the clinical unmet needs, as well as comment on future direction to establish the individual HCC risk more precisely.

A machine learning model for predicting hepatocellular carcinoma risk in patients with chronic hepatitis B

BACKGROUND

Machine learning (ML) algorithms can be used to overcome the prognostic performance limitations of conventional hepatocellular carcinoma (HCC) risk models. We established and validated an ML-based HCC predictive model optimized for patients with chronic hepatitis B (CHB) infections receiving antiviral therapy (AVT).

METHODS

Treatment-naïve CHB patients who were started entecavir (ETV) or tenofovir disoproxil fumarate (TDF) were enrolled. We used a training cohort (n = 960) to develop a novel ML model that predicted HCC development within 5 years and validated the model using an independent external cohort (n = 1937). ML algorithms consider all potential interactions and do not use predefined hypotheses.

RESULTS

The mean age of the patients in the training cohort was 48 years, and most patients (68.9%) were men. During the median 59.3 (interquartile range 45.8-72.3) months of follow-up, 69 (7.2%) patients developed HCC. Our ML-based HCC risk prediction model had an area under the receiver-operating characteristic curve (AUC) of 0.900, which was better than the AUCs of CAMD (0.778) and REAL B (0.772) (both p < .05). The better performance of our model was maintained (AUC = 0.872 vs. 0.788 for CAMD and 0.801 for REAL B) in the validation cohort. Using cut-off probabilities of 0.3 and 0.5, the cumulative incidence of HCC development differed significantly among the three risk groups (p < .001).

CONCLUSIONS

Our new ML model performed better than models in terms of predicting the risk of HCC development in CHB patients receiving AVT.

Prognostic Significance of Hemoglobin, Albumin, Lymphocyte and Platelet (HALP) Score in Hepatocellular Carcinoma

Purpose

HALP score consisting of hemoglobin content, albumin content, lymphocyte count, and platelet count can comprehensively evaluate the inflammatory response and nutritional status. Many researchers have indicated that the HALP score is an effective predictor of the overall prognosis of various tumors. However, there is no relevant research to suggest whether the HALP score can predict the prognosis of patients with hepatocellular carcinoma (HCC).

Patients and Methods

We retrospectively analyzed 273 HCC patients who underwent surgical resection. Hemoglobin content, albumin content, lymphocyte count, and platelet count in peripheral blood were measured for each patient. The relationship between the HALP score and overall survival (OS) was investigated.

Results

With a mean of 56.69 ± 1.25 months follow-up, the 1-, 3-, and 5-year OS was 98.9%, 76.9%, and 55.3% for all patients, respectively. HALP scores (HR=1.708, 95% CI=1.192-2.448, P=0.004) were significant independent risk factors of OS. The 1-, 3-, and 5-year OS were 99.3%, 84.3%, and 63.4% for patients with high HALP scores; and 98.6%, 69.8%, and 47.5% for patients with low HALP scores, respectively (P=0.018). In TNM I-II stage patients, compared with high HALP scores, low HALP scores have worse OS (P=0.039). In AFP positive patients, compared with high HALP scores, low HALP scores have worse OS (P=0.042).

Conclusion

Our research showed the preoperative HALP score is an independent predictive factor of overall prognosis, and a low HALP score indicates a worse prognosis in HCC patients who underwent surgical resection.

Statin use is associated with better post-operative prognosis among patients with hepatitis B virus-related hepatocellular carcinoma

BACKGROUND

The high postoperative recurrence rate of hepatocellular carcinoma (HCC) is a significant challenge. Patient metabolic factors are potential disease modifiers and should be examined as risk factors for postoperative prognosis. Here, we assessed the association between long-term statin use and HCC recurrence after surgical resection of hepatitis B virus (HBV)-related HCC.

METHODS

Patients who initially underwent curative resection for HBV-related HCC between 2005 and 2015 were recruited and followed up until December 2019. Patients were classified into statin user and non-statin user groups based on whether or not they had been prescribed statins for ≥2 years. The primary outcome was HCC recurrence, and the secondary outcome was liver-related mortality. The cumulative incidence by statin use was estimated using the Kaplan-Meier method and compared using the log-rank test. Adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using multivariable Cox regression.

RESULTS

Among 5653 patients with a median 6.1 years of follow-up, HCC recurrence and liver-related mortality occurred in 1603 and 316 patients, respectively. The 5-year cumulative incidence of HCC recurrence in the statin user group (15.9%) was significantly lower than that in the non-user group (21.3%; p = .019). From multivariable Cox regression analysis, statin use was significantly associated with a reduced risk of HCC recurrence (aHR 0.77, 95% CI: 0.61-0.98; p = .035) and liver-related mortality (aHR 0.48, 95% CI: 0.25-0.90; p = .023).

CONCLUSION

Long-term statin use was significantly associated with reduced risk of HCC recurrence and liver-related mortality after curative resection of HBV-related HCC.

Comparable outcomes between immune-tolerant and active phases in noncirrhotic chronic hepatitis B: a meta-analysis

BACKGROUND

Antiviral therapy is not indicated for patients with chronic hepatitis B (CHB) in the immune-tolerant (IT) phase. We compared the outcomes between the untreated IT phase and the treated immune-active (IA) phase in noncirrhotic HBeAg-positive CHB patients.

METHODS

We systematically searched 4 databases, including PubMed, Medline, Embase, and Cochrane, until August 2021. The pooled incidence rates of HCC and mortality in the IT and IA cohorts and phase change in the IT cohort were investigated. Studies that included patients with liver cirrhosis were excluded.

RESULTS

Thirteen studies involving 11,903 patients were included. The overall median of the median follow-up period was 62.4 months. The pooled 5-year and 10-year incidence rates of HCC were statistically similar between the IT and IA cohorts (1.1%, 95% CI: 0.4%-2.8% vs. 1.1%, 95% CI: 0.5%-2.3%, and 2.7%, 95% CI: 1.0%-7.3% vs. 3.6%, 95% CI: 2.4%-5.5%, respectively, all p>0.05). The pooled 5-year odds ratio of HCC between IT and IA cohorts was 1.05 (95% CI: 0.32-3.45; p=0.941). The pooled 5-year incidence rate of mortality was statistically similar between the IT and IA cohorts (1.9%, 95% CI: 1.1%-3.4% vs. 1.0%, 95% CI: 0.3%-2.9%, p=0.285). Finally, the pooled 5-year incidence rate of phase change in the IT cohort was 36.1% (95% CI: 29.5%-43.2%).

CONCLUSION

The pooled incidence rates of HCC and mortality were comparable between the untreated IT and the treated IA phases in noncirrhotic HBeAg-positive CHB patients.

Post-operative recurrence of liver cancer according to antiviral therapy for detectable hepatitis B viremia: A nationwide study

BACKGROUND

High postoperative recurrence of hepatitis B virus (HBV)-infected hepatocellular carcinoma (HCC) remains a significant challenge. Here, we aimed to compare the postoperative HCC recurrence between patients with AVT for detectable serum HBV-DNA vs. those without.

METHODS

Data of patients undergoing curative resection of HBV-infected HCC as an initial therapy from 2015 to 2017 were obtained from the National Health Insurance Service database in South Korea. AVT was initiated when serum HBV-DNA was detectable. The primary outcome was HCC recurrence. The cumulative risk of HCC recurrence between AVT users and non-users was estimated using the Kaplan-Meier method.

RESULTS

During follow-up (median 2.7 years) with 3034 patients, 25.7% and 23.6% of AVT users and non-users experienced HCC recurrence, respectively. The 1-, 2-, and 3-year cumulative recurrence rates were similar (p = 0.57): 15.6%, 23.3%, and 26.4% in AVT users versus 15.3%, 22.0%, and 24.9% in non-users, respectively. After adjusting for covariates, multivariable Cox regression analysis showed comparable outcomes between the two groups with adjusted hazard ratios (aHR 1.08, 95% confidence interval [CI] 0.89-1.31; p = 0.439). Similar outcomes between the two groups were reproduced after stratification of liver cirrhosis. Inverse probability treatment weighting analysis also showed comparable outcomes between the two groups in the subgroups with liver cirrhosis (aHR 1.01, 95% CI 0.80-1.29; p = 0.92) and non-cirrhosis (aHR 1.08, 95% CI 0.87-1.34; p = 0.472).

CONCLUSIONS

Initiating AVT based on detectable serum HBV-DNA provided the similar risk of postoperative HCC recurrence in HBV-infected HCC patients with and without detectable serum HBV-DNA.

Comparable Mortality Between Asian Patients with Chronic Hepatitis B Under Long-Term Antiviral Therapy vs Matched Control: A Population-Based Study

INTRODUCTION

Antiviral therapy (AVT) substantially improved the prognosis for patients with chronic hepatitis B (CHB). Head-to-head comparisons of prognosis between treated patients with CHB and the general population are scarce. We directly compared the prognosis between Asian patients with CHB receiving AVT and the general population.

METHODS

From the South Korean National Health Insurance Service database, patients with CHB receiving AVT ≥3 years, aged 40-64 years, who underwent health examinations between 2011 and 2012 (AVT-CHB group) were recruited. As a control, propensity score-matched general population was chosen among patients without CHB. The primary outcome was all-cause mortality; secondary outcomes were cardiovascular disease (CVD), hepatocellular carcinoma (HCC), and all types of non-HCC malignancies.

RESULTS

During follow-up (median 7.2 years), 26,467 and 75,469 individuals in the AVT-CHB group and matched general population were analyzed. The 5- and 7-year cumulative all-cause mortality rates were 0.40% and 1.0% for the AVT-CHB group vs 0.50% and 1.0% for the matched general population (adjusted hazard ratio [aHR] 0.96, 95% confidence interval [CI] 0.83-1.10; P = 0.51). The AVT-CHB group had a lower risk of CVD than the matched general population (aHR 0.70, 95% CI: 0.62-0.79; P < 0.001). Although the AVT-CHB group was more likely to develop HCC than the matched general population (aHR 13.16, 95% CI: 10.90-15.89; P < 0.001), the non-HCC malignancy risks in the AVT-CHB group were comparable to the matched general population (aHR 1.05, 95% CI 0.98-1.13; P = 0.137).

DISCUSSION

The AVT-CHB group had a similar risk of all-cause mortality and non-HCC malignancies and a lower risk of CVD than the matched general population.

Suboptimal Performance of Hepatocellular Carcinoma Prediction Models in Patients with Hepatitis B Virus-Related Cirrhosis

This study aimed to evaluate the predictive performance of pre-existing well-validated hepatocellular carcinoma (HCC) prediction models, established in patients with HBV-related cirrhosis who started potent antiviral therapy (AVT). We retrospectively reviewed the cases of 1339 treatment-naïve patients with HBV-related cirrhosis who started AVT (median period, 56.8 months). The scores of the pre-existing HCC risk prediction models were calculated at the time of AVT initiation. HCC developed in 211 patients (15.1%), and the cumulative probability of HCC development at 5 years was 14.6%. Multivariate Cox regression analysis revealed that older age (adjusted hazard ratio [aHR], 1.023), lower platelet count (aHR, 0.997), lower serum albumin level (aHR, 0.578), and greater LS value (aHR, 1.012) were associated with HCC development. Harrell’s c-indices of the PAGE-B, modified PAGE-B, modified REACH-B, CAMD, aMAP, HCC-RESCUE, AASL-HCC, Toronto HCC Risk Index, PLAN-B, APA-B, CAGE-B, and SAGE-B models were suboptimal in patients with HBV-related cirrhosis, ranging from 0.565 to 0.667. Nevertheless, almost all patients were well stratified into low-, intermediate-, or high-risk groups according to each model (all log-rank p < 0.05), except for HCC-RESCUE (p = 0.080). Since all low-risk patients had cirrhosis at baseline, they had unneglectable cumulative incidence of HCC development (5-year incidence, 4.9−7.5%). Pre-existing risk prediction models for patients with chronic hepatitis B showed suboptimal predictive performances for the assessment of HCC development in patients with HBV-related cirrhosis.

The Age, Gamma-Glutamyl Transpeptidase and Platelet Index: A Novel Noninvasive Model for Predicting Hepatocellular Carcinoma in Patients with Hepatitis B Virus-Related Liver Cirrhosis

Background and Aims

High incidence of hepatocellular carcinoma (HCC) exists in patients with liver cirrhosis (LC), but the predictive accuracy of noninvasive scoring systems (NSSs) is yet to be elucidated. The present study aimed to evaluate the predictive ability of fibrosis-4 (FIB-4), aminotransferase-to-platelet ratio index (APRI), and gamma-glutamyl transpeptidase to platelet ratio (GPR) in patients with LC, and to establish a new model with more accuracy.

Methods

Data from 94 patients with compensated LC and 134 patients with decompensated cirrhosis (DC) were collected. The prediction accuracy of NSSs, including APRI, GPR, and FIB-4, was compared.

Results

During a median follow-up of 37.5 months, 9 patients in the compensated LC group and 38 in the DC group developed HCC. For 228 patients, the area under the receiver operating characteristic curve (AUROC) of APRI, GPR, and FIB-4 was 0.596, 0.625, and 0.654, respectively. Multivariable logistic analysis showed that age, gamma-glutamyl transpeptidase (GGT), and platelet (PLT) were independent risk factors for HCC development, and a new model encompassing age, GGT, and PLT was superior to NSSs (all P<0.05). With an optimal cutoff value of 0.216, Model (Age_GGT_PLT) achieved 68.09% sensitivity and 69.61% specificity.

Conclusion

NSSs, including APRI, GPR, and FIB-4, has a non-optimal accuracy in predicting HCC development in patients with HBV-related LC. Thus, the new model consisting of age, GGT, and PLT may be more accurate than NSSs.

HBV seroprevalence and liver fibrosis status among population born before national immunization in Southern Thailand: Findings from a health check-up program

Background

Hepatitis B virus (HBV) infection is the leading cause of liver-related death worldwide, particularly in Asia. Patients with either current or past HBV infection are at risk of cirrhosis and hepatocellular carcinoma (HCC). Here, we investigated the HBV seroprevalence in residents of southern Thailand born before the national vaccination program.

Methods

A cross-sectional study of individuals born before the nationwide HBV vaccination program who sought check-up programs which included HBV serology and abdominal ultrasound at a tertiary care hospital in southern Thailand from 2019 to 2020 was conducted. HBV serology, cirrhosis and liver fibrosis status (determined by ultrasonography and FIB-4), and clinical notes regarding management following HBsAg+ detection were obtained.

Results

Of 1,690 eligible individuals, the overall prevalence of HBsAg+ and HBsAg-antiHBc+, indicating current and past HBV infections, were 2.9% and 27.8%, respectively. Among current HBV patients, 87.8% were unaware of their infection. Cirrhosis was found in 8.2%, 1.1%, and 0.3% of patients with current, past, and no HBV infection, respectively (p<0.001). One-fourth of past HBV patients had FIB-4≥1.45, which indicated indeterminate or significant liver fibrosis, which may increase the risk of HCC.

Conclusion

The prevalence of HBsAg+ in Southern Thailand was 2.9%, and that of past infection (HBsAg-antiHBc+) was 27.8%. Patients with current and past HBV infection have an increased risk of cirrhosis and significant liver fibrosis. Most current HBV patients were unaware of their infection. Identifying patients with current and past HBV infection who are at risk for HCC and linking them to a cascade of care is necessary to reduce the burden of HBV-related liver diseases in Thailand.