A study into the risk of exacerbation of chronic hepatitis B after liver resection for hepatocellular carcinoma

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.

Controversies in the Management of Hepatitis B: Hepatocellular Carcinoma

Hepatitis B is the leading cause of hepatocellular cancer (HCC) worldwide. Untreated, annual HCC incidence rates in chronic hepatitis B subjects are 0.4% in noncirrhotics and 2% to 3% in cirrhotics. Surveillance with ultrasound with/without α-fetoprotein at 6-month intervals is recommended in at-risk persons including children. Antiviral therapy in chronic hepatitis B with entecavir or tenofovir significantly lowers the risk of HCC across all stages of liver disease, and lowers the risk of HCC recurrence following curative therapy. There are insufficient data to recommend use of tenofovir over entecavir in the prevention of de novo or recurrent HCC postcurative therapy.

Efficacy of antiviral therapy with nucleotide/nucleoside analogs after curative treatment for patients with hepatitis B virus-related hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

A systematic review was conducted to evaluate whether or not antiviral therapy with nucleotide/nucleoside analogs (NA) have survival benefit for patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) after curative treatment.

METHODS

An electronic search of PubMed, EMBASE, and the Cochrane Library was performed to identify comparative studies in which the adjuvant effects of NA for patients with HBV-related HCC after curative treatment were evaluated. Primary outcome included survival rate, and secondary outcomes included tumor recurrence rate and side effects. Review Manager 5.1.6 software was used for meta-analysis.

RESULTS

Twelve studies involving 6682 patients were included in our review. Meta-analysis results demonstrated that significant differences favoring the antiviral treatment groups were observed in 1-year survival rate (RR: 0.65, 95% CI: 0.53-0.79, P<0.0001), 3-year survival rate (RR: 0.58, 95% CI: 0.46-0.74, P<0.0001), and 5-year survival rate (RR: 0.56, 95% CI: 0.43-0.74, P<0.0001) compared with the control group. After NA was administered, recurrence was significantly reduced after one year (RR: 0.77, 95% CI: 0.64-0.93, P=0.006) and three years (RR: 0.81, 95% CI: 0.71-0.93, P=0.002) but not after five years (RR: 0.94, 95% CI: 0.76-1.16, P=0.55) compared with non-NA therapy.

CONCLUSION

Current evidence showed that antiviral therapy with NA could improve survival and reduce early recurrence for patients with HBV-related HCC after curative treatment. More high-quality prospective trials are expected.

Antiviral therapy improves post-hepatectomy survival in patients with hepatitis B virus-related hepatocellular carcinoma: a prospective-retrospective study

BACKGROUND

The effect of antiviral therapy on the post-hepatectomy long-term survival in patients with hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) remains uncertain.

AIM

To evaluate the effect of antiviral therapy on post-hepatectomy survival and recurrence in patients with HBV-related HCC.

METHODS

This was a prospective-retrospective study of a total of 404 patients who underwent hepatectomy for HBV-related HCC in a tertiary academic hospital. Data on patient and tumour characteristics, tumour recurrence, treatment for recurrence and survival were compared between antiviral and no antiviral groups.

RESULTS

Patient's and tumour characteristics were comparable between the two groups, except a higher proportion of patients with cirrhosis in the antiviral group. With a mean follow-up time of 52.4 months, antiviral group had a better 5-year overall survival (66.7% vs. 56.0%, P = 0.001) while there was no significant difference in the 5-year disease-free survival (44.7% vs. 38.1%, P = 0.166). Use of antiviral therapy was associated with better liver function reserve at the time of recurrence and a greater proportion of patients could receive curative treatment for recurrence (38.5% vs. 24.3%, P = 0.041). There was no significant different in the hazard ratios of patients who started antiviral therapy before or after operation (P = 0.054).

CONCLUSIONS

Use of antiviral therapy improves the long-term post-hepatectomy survival in patients with HBV-related HCC. With a better liver function reserve at the time of recurrence, a greater proportion of patients in antiviral group could receive curative treatment for recurrence.

Does anti-HBV therapy benefit the prognosis of HBV-related hepatocellular carcinoma following hepatectomy?

The Hepatitis B virus (HBV) is an important etiological factor for hepatocarcinogenesis, because HBV DNA load and HBV reactivation are major risks that influence the long-term survival of hepatocellular carcinoma (HCC) patients who underwent hepatectomy and, thus, may cause postoperative liver function deterioration, tumor recurrence, and reduce patient's overall survival. However, anti-HBV therapy can suppress HBV replication, improve the remnant liver function, render patients better able to tolerate HCC treatments, and may even improve their prognosis. In this paper, an anti-HBV therapy that benefits the prognosis of HBV-related HCC following hepatectomy is reviewed.

Hepatitis B viral load affects prognosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a complex disease that is dually challenging to treat due to underlying chronic liver disease in addition to the cancer itself. The prognosis of patients with HCC is determined by intrahepatic tumor status and reserved hepatic function. Hepatitis B virus (HBV) is an established major risk factor of HCC development, and HBV viral load is being increasingly recognized as a prognostic factor in the presence of established HCC. High HBV viral load may affect the prognosis of HBV-related HCC patients in several ways. First, it is associated with more frequent recurrence of HBV-related HCC after treatment. Second, it is associated with more occurrence and severity of potentially life-threatening HBV reactivation. Last, it is associated with more worsened liver function, which limits the therapeutic options for HBV-related HCC. HBV, directly or indirectly, can induce hepatocarcinogenesis. In patients with a high HBV DNA level and subsequent active hepatitis, adhesion molecules expressed on the sinusoidal cells are up-regulated and may increase intrahepatic metastasis. HCC progression after treatment can lead to a poor prognosis by reducing number of normal functioning hepatocytes. Thus, high HBV viral load can affect the prognosis of patients with HCC by frequent recurrence after treatment for HCC and deterioration of hepatic function associated with HCC progression. Recent meta-analysis showed that antiviral treatment reduces HCC recurrence and liver-related mortality after curative therapy of HCC. Given the strong relationship between high HBV DNA load and poor survival outcome of HCC patients due to cancer progression, it is expected that long-term antiviral therapy results in the sustained HBV suppression, control of inflammation, reduction in HCC progression, and eventually in improved overall survival.

Impact of antiviral therapy on post-hepatectomy outcome for hepatitis B-related hepatocellular carcinoma

The outcome after curative resection for hepatocellular carcinoma (HCC) remains unsatisfactory due to the high recurrence rate after surgery. In patients with hepatitis B virus (HBV)-related HCC, which is the majority of patients with HCC in Asia, a high viral load is a strong risk factor for HCC recurrence. It is logical to believe that antiviral therapy may improve the post-operative outcome by promoting viral clearance and hepatocyte regeneration, as well as improving residual liver volume in HCC patients with hepatitis B. However, the effect of antiviral therapy on clinical outcomes after liver resection in patients with HBV-related HCC remains to be established. There are two main groups of antiviral treatment for HBV-oral nucleos(t)ide analogues and interferon. Interferon treatment reduces the overall incidence of HBV-related HCC in sustained responders. However, side effects may limit its long-term clinical application. Nucleos(t)ide analogues carry fewer side effects and are potent in terms of viral suppression when compared to interferon and are typically implemented for patients with more advanced liver diseases. They may also improve the outcome after curative resection for HBV-related HCC. There are increasing evidence to suggest that antiviral therapy could suppress HBV, decrease the perioperative reactivation of viral replication, reduce liver injury, preserve the liver function before and after operation, and may lower the risk of HCC recurrence. After all, antiviral therapy may improve the survival after liver resection by reducing recurrence and delaying the liver damage by the virus, resulting in a higher chance of receiving aggressive salvage therapy during HCC recurrence.

The Role of Antiviral Therapy for HBV-Related Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a highly prevalent and lethal cancer worldwide; despite the curative treatment for HCC, the rate of tumor recurrence after hepatectomy remains high. Tumor recurrence can occur early (<2 years) or late (>2 years) as metastases or de novo tumors. Several tumor factors were associated with HCC recurrence; high hepatitis B virus (HBV) load is the major risk factor for late recurrence of HCC after resection. Preoperative antiviral therapy improves liver function, and postoperative reduce HCC recurrence. In this paper, we focus on antiviral treatment to improve the liver function, prevent recurrence, and lengthen the overall survival for HBV-related HCC.