Postoperative peg-interferon plus ribavirin is associated with reduced recurrence of hepatitis C virus-related hepatocellular carcinoma

Suppression of hepatocellular carcinoma development in hepatitis C patients given interferon-based antiviral therapy

The advance of antiviral treatment for chronic hepatitis C has brought a high sustained virological response (SVR) rate. In this review article, the suppressive effect of interferon (IFN)-based therapy on the development of hepatocellular carcinoma (HCC), risk factors for developing HCC and the characteristics of HCC development after SVR among chronic hepatitis C patients given IFN-based therapy were studied. The HCC incidence has been revealed to decrease with IFN-based antiviral therapy, especially in SVR, and the risk factors for developing HCC were older age, advanced liver fibrosis and male sex. α-Fetoprotein levels at 24 weeks after the end of IFN-based treatment was associated strongly with HCC incidence irrespective of virological response. In patients with SVR, other risk factors were glucose metabolism disorders, lipid metabolism disorders and alcohol intake. Extra attention to the possibility of HCC incidence should be required for these SVR patients. Antiviral therapy with a combination of HCV-specific direct-acting antivirals (DAA) is expected to be utilized in the future. However, it is not known whether DAA-based treatment can suppress HCC to the level of IFN-based treatment. Further research is required to clarify this.

Asunaprevir-containing regimens for the treatment of hepatitis C virus infection

Chronic hepatitis C virus (HCV) infection has been a tremendous health burden worldwide with an annual mortality of 300,000 people due to decompensated cirrhosis or hepatocellular carcinoma. A combination of interferon (IFN), ribavirin (RBV), and/or direct-acting antivirals (DAAs) can eradicate HCV in a various proportion of infected patients. Unfortunately, IFN-based therapy is associated with significant adverse effects, contraindications, and limited tolerability, leading to lower adherence or even treatment discontinuation. With the rapid evolution of newer DAAs or host-targeting agents, emerging HCV therapy is moving towards an IFN- and RBV-free strategy. To this end, a recently developed NS3 protease inhibitor, asunaprevir (ASV), in combination with other DAAs as IFN/RBV-containing or -free regimen, has shown promising results with fewer adverse effects. In this review, preclinical profiles and clinical proof-of-concept studies of ASV, including viral resistance, host polymorphism, and role of ASV in future HCV therapy are reviewed and discussed.

Radiofrequency ablation versus surgical resection for small unifocal hepatocellular carcinomas

We aimed to compare the effectiveness and safety of hepatic resection and radiofrequency ablation (RFA) for small hepatocellular carcinomas (HCCs) less than 5 cm in diameter. A total of 289 patients were diagnosed with a small HCC (a single tumor no larger than 5 cm). Among these patients, 133 underwent hepatic resection, and 156 received RFA. Demographic data, intraoperative data, post-operative recovery data, and the baseline characteristics of the 2 groups of patients were compared. The incidence of post-operative complications; 1-, 3-, and 5-year survival rates; and tumor recurrence were determined. No statistically significant differences in the baseline characteristics were noted between the 2 groups. By contrast, operation time (P = 0.003), intraoperative blood loss (P = 0.000), and the length of post-operative hospital stay (P = 0.000) were significantly lower in the RFA group compared with the surgical resection group. The 2 groups displayed similar post-operative complication rates (12% or 16/133 in the liver resection group vs. 8.3% or 13/156 in the RFA group, P = 0.395). The 1-, 3-, and 5-year overall survival rates of the patients in the liver resection group were 88.7%, 78.2%, and 66.2%, respectively, whereas the rates in the RFA group were 90.4%, 76.3%, and 66.0%, respectively (P = 0.722). The 1-, 3-, and 5-year tumor-free survival rates of patients in the resection group were 87.2%, 69.9%, and 58.6%, respectively, whereas the rates in the RFA group were 85.9%, 66.0%, and 54.5%, respectively (P = 0.327). In addition, among HCC patients receiving RFA, patients with tumors no greater than 3 cm in diameter exhibited no significant differences regarding overall survival and tumor-free survival rates compared with patients with tumors 3 to 5 cm in diameter (all P > 0.05). RFA is an effective and safe treatment option for small HCCs and may be a preferred choice for HCC patients with small lesions.

Determinants of hepatocellular carcinoma in cirrhotic patients treated with nucleos(t)ide analogues for chronic hepatitis B

OBJECTIVES

We aimed to identify determinants of hepatocellular carcinoma (HCC) in cirrhotic patients who received nucleos(t)ide analogues for chronic hepatitis B (CHB).

PATIENTS AND METHODS

This retrospective-prospective study screened all patients (n = 1630) who received antiviral therapy for CHB between 1 September 2007 and 31 March 2013 at the E-Da Hospital and enrolled 210 consecutive cirrhotic patients with pretreatment viral DNA >2000 IU/mL. Those who developed HCC within 3 months of treatment were excluded. All participants were observed until occurrence of HCC, death or 1 January 2014. The incidence and determinants of HCC were estimated using competing risk analyses adjusted for mortality.

RESULTS

Thirty-five (16.7%) patients developed HCC during a median follow-up of 25.2 months (IQR, 16.3-37.3 months), with a cumulative incidence of 24.1% (95% CI, 16.3%-32.0%) at 5 years. Multivariate-adjusted analyses identified age >55 years [adjusted hazard ratio (HR), 2.19; 95% CI, 1.03-4.66], male gender (adjusted HR, 3.07; 95% CI, 1.05-9.02), model for end-stage liver disease (MELD) score >12 points (adjusted HR, 2.16; 95% CI, 1.10-4.23) and diabetes mellitus (DM; adjusted HR, 3.49; 95% CI, 1.54-7.91) as independent risk factors after adjusting for multiple covariates, including antidiabetes medication. A scoring formula that used information on age, gender, MELD score, DM and antidiabetes regimen significantly discriminated patients at high or low risk of HCC, with sensitivity and specificity of 82.9% and 62.3%, respectively.

CONCLUSIONS

Age, gender, hepatic dysfunction, DM and medication for DM are baseline factors that stratify the risk of HCC in cirrhotic patients who receive nucleos(t)ide analogues for CHB.

Usefulness of a new inflammation-based scoring system for prognostication of patients with hepatocellular carcinoma after hepatectomy

BACKGROUND

We investigated whether a preoperative scoring system (the "CRP-AFP Score [CAS]") based on the serum levels of C-reactive protein and alpha-fetoprotein would predict outcome in patients undergoing hepatectomy for hepatocellular carcinoma.

METHODS

The CAS was defined as follows: patients with an elevated level of both C-reactive protein (>.3 mg/dL) and alpha-fetoprotein (>20 ng/mL) were assigned a score of 2, and patients showing one or none of these abnormalities were assigned a score of 1 or 0, respectively.

RESULTS

A total of 349 patients were identified. Pathologic findings, in terms of tumor size, histologic grade, vascular invasion, intrahepatic metastasis, and recurrence rate, worsened as the CAS increased. CAS 2 patients had a poorer 5-year overall survival than CAS 0 or 1 patients (32.2% vs 59.7% vs 49.2%, respectively; P < .001).

CONCLUSIONS

The CAS is an informative scoring system that can predict outcome in patients with hepatocellular carcinoma after hepatectomy.

Antiviral treatment for hepatitis C virus infection is associated with improved renal and cardiovascular outcomes in diabetic patients

Hepatitis C virus (HCV) infection is causally associated with insulin resistance and diabetes mellitus. This population-based cohort study aimed to investigate whether antiviral therapy for HCV infection was associated with improved clinical outcomes related to diabetes. From the Taiwan National Health Insurance Research Database, 2,267,270 Taiwanese residents diagnosed with diabetes mellitus were screened for eligibility. HCV infection was defined by a specific diagnosis code and measurement of serum antibody. After excluding patients with serious comorbidity, we enrolled a total of 1,411 eligible patients who received pegylated interferon plus ribavirin (treated cohort), and matched them 1:1 with 1,411 untreated controls by propensity scores (untreated cohort). We also matched the treated cohort 1:4 with 5,644 diabetic patients without HCV infection (uninfected cohort). Participants were followed up for the occurrence of endstage renal disease (ESRD), ischemic stroke, and acute coronary syndrome (ACS) after receiving antiviral treatment or the corresponding calendar date. From 2003 to 2011, the 8-year cumulative incidences of ESRD in the treated, untreated, and uninfected cohorts were 1.1% (95% confidence interval [CI], 0.3-2.0%), 9.3% (95% CI, 5.9-12.7%), and 3.3% (95% CI, 2.3-4.3%), respectively (P < 0.001); those of stroke were 3.1% (95% CI, 1.1-5.0%), 5.3% (95% CI, 3.0-7.5%), and 6.1% (95% CI, 4.8-7.4%), respectively (P = 0.01); and those for ACS were 4.1% (95% CI, 2.1-6.1%), 6.6% (95% CI, 3.7-9.5%), and 7.4% (95% CI, 5.9-9.0%), respectively (P = 0.05). As compared with the untreated cohort, antiviral treatment was associated with multivariate-adjusted hazard ratios of 0.16 (95% CI, 0.07-0.33%) for ESRD, 0.53 (95% CI, 0.30-0.93) for ischemic stroke, and 0.64 (95% CI, 0.39-1.06) for ACS.

CONCLUSION

Antiviral treatment for HCV infection is associated with improved renal and cardiovascular outcomes in diabetic patients.

Hepatitis C-related liver cirrhosis - strategies for the prevention of hepatic decompensation, hepatocarcinogenesis, and mortality

Liver cirrhosis (LC) is a critical stage of chronic liver disease, including that caused by hepatitis C virus (HCV). In the absence of antiviral therapy, 67%-91% of patients with HCV-related LC patients die of liver-related causes, including hepatocellular carcinoma (HCC) and liver failure. Among the therapeutic strategies used to prevent liver-related complications in these patients is standard therapy with pegylated interferon and ribavirin, which induces a sustained virological response (SVR) in 25% of HCV genotype 1-infected patients and in 69% of patients infected with genotypes 2 and 3. SVR in patients with HCV-related LC has been associated with reduced rates of hepatic decompensation, HCC, and mortality. More recently developed direct-acting antiviral agents have shown excellent antiviral efficacy, with preliminary data demonstrating that an interferon-free regimen that includes these direct-acting antiviral agents achieved SVR in more than 50% of patients with HCV genotype 1 LC. Branched-chain amino acid supplementation, improvement of insulin resistance, and the use of β-blockers for portal hypertension may also reduce liver-related complications. Here, we review advances in antiviral and adjunctive therapies for improved outcomes in patients with HCV-associated LC.

Chemopreventive strategies in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the third most common cause of death from cancer. The incidence and mortality of HCC are increasing in most Western countries as a result of an ageing cohort infected with chronic hepatitis C, and are expected to continue to rise as a consequence of the obesity epidemic. Chemopreventive strategies aimed at decreasing the risk or delaying the onset of HCC are needed. Universal immunization against HBV and antiviral therapy against HBV and HCV in patients with established disease has consistently been associated with reduced HCC risk, especially in patients who achieve sustained virologic response. However, the cost-effectiveness of antiviral therapy for primary HCC prevention is not known. Several commonly prescribed medications seem promising as chemopreventive agents against HCC, including statins, antidiabetic medications and aspirin. Dietary agents such as coffee, vitamin E and fish oil as well as phytochemicals might also be associated with reduced risk of HCC. Though randomized controlled trials are ideally needed to firmly establish efficacy, such chemoprevention trials are logistically and ethically challenging. Well-designed, prospective, population-based cohort studies might provide the best evidence for chemopreventive efficacy of these agents.