Hepatitis C virus and other risk factors in hepatocellular carcinoma

Differential Association of Hepatocellular Carcinoma Related to Hepatitis B Between Urban and Rural Areas in Africa Using Satellite Spatial Scaling Data

PURPOSE

Sub-Saharan Africa carries one of the highest burdens of hepatocellular carcinoma (HCC) in the world, with hepatitis B virus (HBV) as the most common cause. Studies in several regions of the world suggest important cancer differences in rural versus urban settings, but limited studies have been performed in Africa.

METHODS

We performed a scoping review and pooled analysis of studies on HCC in Africa. Using land use data from the European Space Agency, we calculated the distance in kilometers from each study site to the nearest rural area. Regression models were fit to estimate the association between distance to the nearest rural area and HBV, sex, and weighted mean age.

RESULTS

Data from 57 studies including 10,907 patients across 36 towns/cities were included in our analysis. Proximity to rural areas was associated with a higher frequency of HBV-associated HCC in assessment of distance both at midpoint and at quartiles after controlling for country: risk ratio (RR) 1.71 (95% CI, 1.52 to 1.93) and RR 1.51 (95% CI, 1.25 to 1.84), respectively. No association was found between sex and proximity to a rural area: RR 1.02 (95% CI, 0.96 to 1.08). The weighted mean age across the four distance quartiles was 50.09, 53.43, 47.98, and 53.35 years with no statistically significant difference found across the quartiles (P = .81).

CONCLUSION

Individuals living in rural Africa have a higher rate of HBV-related HCC compared with other liver diseases. Increased HBV awareness efforts in these areas should be considered.

A Network Map of Intracellular Alpha-Fetoprotein Signalling in Hepatocellular Carcinoma

Alpha fetoprotein (AFP) is a glycoprotein of foetal origin belonging to the albumin protein family. Serum AFP is a long-conceived early-diagnostic biomarker for HCC with its elevated expression in different liver pathologies ranging from hepatitis viral infections to fibrosis, cirrhosis, and HCC. Beyond their utility as biomarkers, in support of its contribution to these clinical outcomes, the function of AFP as an immune suppressor and inducer of malignant transformation in HCC patients is well reported. Multiple reports show that AFP is secreted by hepatocytes, binds to its cognate receptor, AFP-receptor (AFPR), and exerts its actions. However, there is only limited information available in this context. There is an urgent need to gather more insight into the AFP signalling pathway and consider it a classical intracellular signalling pathway, among others. AFP is a highly potent intracellular molecule that has the potential to bind to many interactors like PTEN, Caspase, RAR, and so on. It has been shown that cellular AFP and secreted AFP have different roles in HCC pathophysiology, and a comprehensive map of the AFP signalling pathway is warranted for further theranostic applications.

Hepatitis B, C and D virus infections and risk of hepatocellular carcinoma in Africa: A meta-analysis including sensitivity analyses for studies comparable for confounders

INTRODUCTION

Africa denotes unique facies for hepatocellular carcinoma (HCC) characterized by a conjunction of low sensitization, restricted access to diagnosis and treatment and associated with the highest incidence and mortality in the world. We investigated whether hepatitis B (HBV), C (HCV) and D (VHD) viruses were etiological agents of HCC in Africa.

METHODS

Relevant articles were searched in PubMed, Web of Science, African Index Medicus, and African Journal Online databases, as well as manual searches in relevant reviews and included articles. Analytical studies from Africa evaluating the association between HCC development and HBV, HCV, and HDV were included. Relevant studies were selected, data extracted, and the risk of bias assessed independently by at least 2 investigators. The association was estimated using odds ratios (OR) and their 95% confidence interval (95% CI) determined by a random-effects model. Sources of heterogeneity were determined by subgroup analyses.

RESULTS

A total of 36 case-control studies were included. With controls having non-hepatic disease, the overall results suggested a significantly increased risk of HCC in patients with HBV (HBeAg (OR = 19.9; 95% CI = [3.7-105.2]), HBsAg (OR = 9.9; 95%) CI = [6.2-15.6]) and DNA (OR = 8.9; 95% CI = [5.9-13.4]); HCV (Anti-HCV (OR = 9.4; 95% CI = [6.3-14.0]) and RNA (OR = 16.5; 95% CI = [7.8-34.6]); HDV (Anti-VHD, (OR = 25.8; 95% CI = [5.9-112.2]); and HBV/HCV coinfections (HBV DNA/HCV RNA (OR = 22.5; 95% CI = [1.3-387.8]). With apparently healthy controls, the overall results suggested a significantly increased risk of HCC in patients with HBV (HBsAg, (OR = 8.9; 95% CI = [6.0-13.0]); HCV (Anti-HCV, (OR = 7.7; 95% CI = [5.6-10.6]); and HBV/HCV coinfections (HBsAg/Anti-HCV (OR = 7.8; 95% CI = [4.4-13.6]) Substantial heterogeneity and the absence of publication bias were recorded for these results.

CONCLUSIONS

In Africa, HBV/HCV coinfections and HBV, HCV, and HDV infections are associated with an increased risk of developing HCC. The implementation of large-scale longitudinal and prospective studies including healthy participants to search for early biomarkers of the risk of progression to HCC is urgently needed.

Yttrium-90 microsphere radioembolisation for unresectable hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the most common liver neoplasm and the sixth most common cancer worldwide. Its incidence has increased dramatically since the mid-2000s. Although surgical resection and liver transplantation are the main curative treatments, only about 20% of people with early hepatocellular carcinoma may benefit from these interventions. Treatment options for unresectable hepatocellular carcinoma include ablative and transarterial interventions - selective yttrium-90 microsphere transarterial radioembolisation - in addition to the drug sorafenib.

OBJECTIVES

To determine the benefits and harms of yttrium-90 (Y-90) microsphere transarterial radioembolisation given as monotherapy or in combination with other systemic or locoregional interventions versus placebo, no treatment, or other similar systemic or locoregional interventions for people with unresectable hepatocellular carcinoma.

SEARCH METHODS

We performed electronic searches in the Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, CENTRAL, MEDLINE, Embase, Latin American Caribbean Health Sciences Literature (LILACS), Science Citation Index - Expanded, and Conference Proceedings Citation Index - Science until September 2019. We manually checked the reference lists of primary studies and review articles.

SELECTION CRITERIA

We searched for randomised clinical trials.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. We extracted information on participants, interventions, outcomes, trial design, and trial methods. We assessed risk of bias of the included trials using pre-defined domains and the certainty of evidence using GRADE. Our primary review outcomes were all-cause mortality, quality of life, and serious adverse events; our secondary outcomes were cancer-related mortality, time to progression of the tumour, tumour response, non-serious adverse events, and liver transplantation. For dichotomous variables, we calculated risk ratio (RR), and for continuous variables, we planned to calculate mean difference (MD) or standardised mean difference (SMD), with 95% confidence intervals (CIs). We based time-to-event data analyses on hazard ratios (HRs).

MAIN RESULTS

Six randomised trials with 1340 participants in total fulfilled the review inclusion criteria and provided data for one or more of our analysed outcomes. All trials were at high risk of bias. We assessed the certainty of evidence as low to very low. One trial compared radioembolisation plus sorafenib versus sorafenib alone in people with advanced hepatocellular carcinoma. All-cause mortality, health-related quality of life, cancer-related mortality, time to progression, and tumour response rates were not reported. Serious adverse events were reported in 63 trial participants (39.6%) in the radioembolisation plus sorafenib group versus 70 trial participants (38.5%) in the sorafenib group (very low-certainty evidence). Hyperbilirubinaemia was approximately three times more common in the radioembolisation plus sorafenib group versus the sorafenib group (14.5% versus 4.4%; very low-certainty evidence). Fatigue was more common in the radioembolisation plus sorafenib group than in the sorafenib group, at 35.2% versus 24.2% of trial participants. Two trials compared radioembolisation versus sorafenib for unresectable hepatocellular carcinoma in people with locally advanced hepatocellular carcinoma. From the data we could extract, one-year all-cause mortality was 62.7% in the radioembolisation group versus 53.0% in the sorafenib group (1 trial; n = 360; very low-certainty evidence). There were no differences in the quality of life between radioembolisation and sorafenib groups (1 trial). Global health status subscore was better in the radioembolisation group than in the sorafenib group (P = 0.0048; 1 trial). Fewer participants had serious adverse events in the radioembolisation group than in the sorafenib group (27 (20.8%) in the radioembolisation group versus 57 (35.2%) in the sorafenib group; 1 trial). Median time to progression of the tumour in the radioembolisation group was 6.1 months versus 5.4 months in the sorafenib group (1 trial). The RR for disease control rate was 0.94 (95% CI 0.84 to 1.05; n = 748; 2 trials; very low-certainty evidence), favouring neither radioembolisation nor sorafenib. In two trials with 734 participants, radioembolisation seemed to be less likely to be associated with hand-foot skin reaction (RR 0.02, 95% CI 0.00 to 0.06; P < 0.001; low-certainty evidence), skin rash (RR 0.11, 95% CI 0.04 to 0.34; low-certainty evidence), diarrhoea (RR 0.11, 95% CI 0.04 to 0.34; low-certainty evidence), and hypertension (RR 0.10, 95% CI 0.01 to 0.88; low-certainty evidence). No trial reported cancer-related mortality. Three trials compared radioembolisation versus chemoembolisation in people with intermediate-stage hepatocellular carcinoma. From the data we could extract, none of these trials reported all-cause mortality and cancer-related mortality. The RR for serious adverse events was 1.41 (95% CI 0.63 to 3.14; n = 97; very low-certainty evidence), favouring neither radioembolisation nor chemoembolisation. One trial reported quality of life and noted no differences between intervention groups with regard to this outcome at week 12 (very low-certainty evidence). Median time to progression was not reached in the radioembolisation group and was 6.8 months in the chemoembolisation group (HR 0.122, 95% CI 0.027 to 0.557; 1 trial). Median time to progression of the tumour in the radioembolisation group was 371 days versus 336 days in the chemoembolisation group (P = 0.5764; 1 trial). Disease control rates (complete response + partial response + stable disease) were 73.3% with radioembolisation versus 76.9% with chemoembolisation (1 trial). According to World Health Organization (WHO) criteria, tumour response was reported in 52% of participants who received radioembolisation versus 63% of those who received chemoembolisation (1 trial). Patients in the chemoembolisation group experienced diarrhoea (P = 0.031; 1 trial) and hypoalbuminaemia (P < 0.001; 1 trial) more frequently. Four trials were sponsored by industry, and two by University. We found two ongoing trials.

AUTHORS' CONCLUSIONS

Evidence showing effects of radioembolisation with or without sorafenib compared with sorafenib alone in people with unresectable hepatocellular carcinoma is highly insufficient. We cannot determine if radioembolisation plus sorafenib compared with sorafenib alone affects all-cause mortality or the occurrence of adverse events. Radioembolisation compared with sorafenib seemed to achieve equivalent survival and to cause fewer adverse effects, but our certainty was very low. Evidence showing effects of radioembolisation versus chemoembolisation in people with unresectable hepatocellular carcinoma is also highly insufficient. Radioembolisation did not seem to differ from chemoembolisation in terms of serious adverse events and quality of life, but the certainty of evidence was very low. Further high-quality placebo-controlled randomised clinical trials are needed to assess patient-centred outcomes.

Pesticide exposure and liver cancer: a review

PURPOSE

To review the epidemiologic literature examining pesticide exposure and liver cancer incidence.

METHODS

A search of the MEDLINE and Embase databases was conducted in October 2015. Eligibility criteria included examining hepatocellular carcinoma (HCC) or primary liver cancer, pesticides as an exposure of interest, and individual-level incidence. The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Forty-eight papers were assessed for eligibility and 15 studies were included in the review. The majority of studies were conducted in China and Egypt (n = 8), used a case-control design (n = 14), and examined HCC (n = 14). Most studies showed no association between self-reported and/or occupational exposure to pesticides and liver cancer risk. Six studies demonstrated statistically significant positive associations, including three biomarker-based studies (two using pre-diagnostic sera) that reported higher serum levels of dichlorodiphenyltrichloroethane (DDT) were associated with increased HCC risk. Studies indirectly measuring pesticide exposure using self-reported exposure, occupation, job-exposure matrices, or geographic residence demonstrated inconsistent results. These studies were limited by exposure assessment methods, lack of confounder information, minimal case confirmation, selection bias, and/or over-adjustment.

CONCLUSIONS

There is mixed evidence suggesting a possible association between specific pesticides and HCC risk, with the strongest evidence observed in biomarker-based studies. In particular, organochlorine pesticides, including DDT, may increase HCC risk. Future research should focus on improved pesticide exposure assessment methods, potentially incorporating multiple approaches including biomonitoring while considering the chemicals of interest, historical exposure to address latency periods, and examining specific chemicals and exposure pathways.

Relative Importance of Hepatitis B and C Viruses in Hepatocellular Carcinoma in EMRO Countries and the Middle East: A Systematic Review

CONTEXT

Hepatocellular carcinoma (HCC) is the second most common cancer-related death worldwide. Although many factors including dietary aflatoxin B1 (AFB1) and alcoholic and non-alcoholic fatty liver diseases can lead to HCC, globally most HCC cases are due to hepatitis B virus (HBV) and hepatitis C virus (HCV). Considering the importance of these viral factors in most HCC cases and relative lack of literature from eastern Mediterranean region office of world health organization (EMRO) countries and the Middle East, we decided to perform this systematic review to find distribution of viral etiology of HCC in these regions.

EVIDENCE ACQUISITION

In this systemic review, we included all studies from 1 January 1989 to 1 September 2015 with at least 20 samples that measured HBV surface antigen (HBsAg) and antibodies to HCV (anti-HCV). The authors searched MEDLINE, Embase, Popline, Web of Science and WHO indexed databases. We searched the following MeSH terms; hepatocellular carcinoma, hepatitis B virus and hepatitis C virus or hepacvirus. Only studies using second- and third-generation HCV assays were included. Only articles studying HCC patients from EMRO countries and the Middle East were analyzed. Duplicate results that reported the same cases more than once were found and omitted. Studies in English and Farsi were reviewed. If the study was eligible, we recorded the following data; the first author, publication year and journal, study population and number and percentage of patients with different serologic statuses.

RESULTS

We found 44 studies from 12 countries in EMRO and the Middle East. HCC cases from Iran, Lebanon, Turkey and Yemen were mainly due to HBV, while those of North African nations (Egypt, Tunisia, Morocco, Algeria and Somalia) in addition to Saudi Arabia and Pakistan were mostly HCV related. Sudan showed a high seronegativity and HBV infection in its HCC cases. Unfortunately, some countries from EMRO and the Middle East did not have eligible studies.

CONCLUSIONS

HBV and HCV are important culprits of HCC in EMRO countries and the Middle East and different nations need different strategies to tackle them accordingly. Countries with high rates of HBV such as Turkey should continue their HBV vaccination and also increase sanitation. Nations with high HCV rates such as Egypt should maintain their blood product monitoring in addition to increased sanitation, especially regarding injection drug users (IDU).

Yttrium-90 microsphere radioembolisation for unresectable hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma is the most common liver neoplasm and the fifth most common cancer worldwide. Moreover, its incidence has increased dramatically since the mid-2000s. While surgical resection and liver transplantation are the main curative treatments, only around 20% of people with early hepatocellular carcinoma may benefit from these therapies. Current treatment options for unresectable hepatocellular carcinoma include various ablative and trans-arterial therapies in addition to the drug sorafenib.

OBJECTIVES

To determine the benefits and harms of yttrium-90 microsphere trans-arterial radioembolisation either as a monotherapy or in combination with other systemic or locoregional therapies versus placebo, no treatment, or other similar systemic or locoregional therapies for people with unresectable hepatocellular carcinoma.

SEARCH METHODS

We reviewed data from the Cochrane Hepato-Biliary Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded. We also checked reference lists of primary original studies and review articles manually for further related articles (cross-references) up to December 2015.

SELECTION CRITERIA

Eligible studies included all randomised clinical trials comparing yttrium-90-90 microsphere radioembolisation either as a monotherapy or in combination with other systemic or locoregional therapies versus placebo, no treatment, or other systemic or locoregional therapies for unresectable hepatocellular carcinoma.

DATA COLLECTION AND ANALYSIS

The two review authors independently extracted the relevant information on participant characteristics, interventions, study outcomes, and data on the outcomes for this review, as well as information on the design and methodology of the studies. The two review authors assessed risk of bias of the included trials using pre-defined risk of bias domains. We used Trial Sequential Analysis to control the risk of random errors. We assessed the methodological quality with GRADE.

MAIN RESULTS

Two randomised clinical trials with 68 participants fulfilled our inclusion criteria. Both trials were at high risk of bias, and we rated the evidence as very low quality. One of the included trials compared radioembolisation versus chemoembolization for intermediate stage hepatocellular carcinoma as classified by the Barcelona Clinic Liver Cancer (BCLC) staging system, while the other included trial was an interim analysis of a randomised trial assessing radioembolisation combined with sorafenib versus sorafenib monotherapy in participants with BCLC-advanced stage hepatocellular carcinoma. The available data were insufficient to perform the planned analyses. Neither of the two trials reported data on all-cause mortality, cancer-related mortality, or time to progression of the tumour. The trial comparing radioembolisation with chemoembolization reported quality of life and serious adverse events, and there were no statistically significant differences between the trial groups with regard to these outcomes at week 12. On the basis of the two included randomised clinical trials, single-session radioembolisation appeared to be as safe as multiple sessions of chemoembolization for intermediate stage hepatocellular carcinoma and had a similar impact on quality of life, but data were too sparse to exclude even major differences. Radioembolisation followed by sorafenib appeared to be as well tolerated as sorafenib alone for advanced stage hepatocellular carcinoma, but data were too sparse to exclude even major differences. We also identified five ongoing studies evaluating the topic of our review.

AUTHORS' CONCLUSIONS

There was insufficient evidence to assess the beneficial and harmful effects of yttrium-90 microsphere radioembolisation for people with unresectable hepatocellular carcinoma. Further randomised clinical trials are mandatory to better assess the potential beneficial and harmful outcomes of yttrium-90 microsphere trans-arterial radioembolisation either as a monotherapy or in combination with other systemic or locoregional therapies versus placebo, no treatment, or other systemic or locoregional therapies for people with unresectable hepatocellular carcinoma.

Combination of transarterial chemoembolisation (TACE) plus antivirals for the management of hepatitis B-related hepatocellular carcinoma: A systematic review of the literature

BACKGROUND

Hepatocellular carcinoma (HCC) is the most frequently occurring liver neoplasm and the fifth most common cancer worldwide. Intermediate-stage HCC is a distinct disease entity that is traditionally treated with transarterial chemoembolisation (TACE). However, the risk of viral reactivation and subsequent hepatic decompensation is considerable. Therefore, in this systematic review, we explore the evidence surrounding the benefits of using TACE/antiviral combination in this subset of HCC.

METHODS

PubMed, Medline, the Cochrane Library, Trip Database, and Google Scholar were searched using the terms "Hepatocellular carcinoma" OR "Hepatoma" or "Liver cancer" AND "Transarterial chemoembolisation" OR "Chemoembolisation" AND "Antivirals" and specifying only English literature. The outcomes of interest included progression-free survival and overall survival (PFS and OS), tumour response, and toxicities.

RESULTS

A total of six potentially relevant trials were identified, from which one study was excluded. Hence, five trials involving 818 patients were included, encompassing three phase II studies and two retrospective studies. The median PFS was reported in one out of the five studies, which was 23 months in the combination arm versus 20 months in the TACE-only arm. The median OS was reported in one out of the four studies: 29 months in the combination arm versus 26 months in the TACE-only arm. The hepatic toxicity parameters showed consistent benefit for the combination arm versus the TACE-only arm in the five studies included.

CONCLUSIONS

An antiviral/TACE combination shows promise as an effective and tolerable treatment strategy for intermediate-stage HCC. The reported efficacy and toxicity of the antiviral/TACE combination appears to compare favorably with TACE monotherapy, the most commonly implemented strategy for intermediate-stage HCC. Further clinical studies are warranted to accurately determine which patients are expected to benefit most from such combination strategies.

Combination trans arterial chemoembolization (TACE) plus sorafenib for the management of unresectable hepatocellular carcinoma: a systematic review of the literature

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common liver neoplasm and the fifth most common cancer worldwide. Intermediate stage HCC [traditionally defined as Barcelona Clinic Liver Cancer (BCLC) B disease and traditionally treated with trans arterial chemoembolization (TACE)] and advanced stage HCC (traditionally defined as BCLC C disease and traditionally treated with sorafenib) are two distinct disease entities with rapidly evolving multimodality treatment approaches. In this systematic review we explore the evidence surrounding the value of using a TACE/sorafenib combination in these two subsets of HCC.

METHODS

PubMed, Medline, the Cochrane Library, EMBASE and Google Scholar were searched using the terms "HCC" OR "Hepatoma" or "Liver cancer" AND "TACE" OR "Chemoembolization" AND "Sorafenib" and specifying only English literature. Outcomes of interest included time to progression and overall survival (TTP and OS), tumor response, and toxicities.

RESULTS

A total of 17 potentially relevant trials were identified, of which six studies were excluded. Hence, 11 trials involving 1,000 patients were included, encompassing two phase 1 studies, one phase 3 study, two retrospective analyses and six phase 2 studies. Median TTP was reported in five out of 11 studies and it ranged from 6.3 to 9.0 months. Median OS was reported in five out of 11 studies and it was similarly variable as PFS, ranging from 12 to 29 months. The DCR (disease control rate) was reported in eight out of 11 studies, ranging from 32 to 95%. Frequently reported grade 3/4 toxicities were increased aspartate transaminase/alanine transaminase, fatigue, hypertension, hand-foot skin reaction and diarrhea.

CONCLUSIONS

The sorafenib/TACE combination shows promise as an effective and tolerable treatment strategy for intermediate stage/advanced HCC. The reported efficacy of a sorafenib/TACE combination appears to compare favorably with sorafenib or TACE monotherapies, the most commonly implemented strategies for unresectable HCC. Further clinical studies are warranted to accurately determine which patients are expected to benefit most from such combination strategies.

Sorafenib versus capecitabine in the management of advanced hepatocellular carcinoma

The only approved systemic therapy for patients with advanced hepatocellular carcinoma (HCC) till now is sorafenib. A preliminary study suggested that capecitabine, an oral fluoropyrimidine, may be effective in advanced HCC. We have tested this hypothesis in this phase 2 study. In this single-center, phase 2, open-label trial, we randomly assigned 52 patients with advanced HCC who had not received previous systemic treatment to receive either sorafenib (at a dose of 400 mg twice daily) or capecitabine (1,000 mg/m(2) twice daily) (day 1-day 14). Primary outcome was progression-free survival. Secondary outcomes included the overall survival and safety. Median overall survival was 7.05 months in the sorafenib group and 5.07 months in the capecitabine group (hazard ratio in the capecitabine group 2.36; 95 % confidence interval 1.174-4.74; P < 0.016). The median progression-free survival was 6 months in the sorafenib group and 4 months in the capecitabine group (P < 0.005). Three patients in the sorafenib group (11.5 %) and one patient in the capecitabine group (3 %) had a partial response; one patient (3 %) had a complete response in the sorafenib group. Hand-foot skin reaction was more frequent in the sorafenib group, hyperbilirubinemia was more common in the capecitabine group, and diarrhea was equivalent between both groups. In patients with advanced HCC, capecitabine is inferior to sorafenib in terms of median progression-free survival and overall survival, and it should not be used alone for the treatment of advanced HCC, but rather, combination therapy with sorafenib should be considered.

The effectiveness of stem cell therapies on health-related quality of life and life expectancy in comparison with conventional supportive medical treatment in patients suffering from end-stage liver disease

The work presented in this study focuses on evaluating health-related quality of life using the International Short Form 36-Item Health Survey in chronic liver disease patients in Cairo, Egypt, who received either stem cell therapy (SCT) or supportive medical treatment (SMT). Long-term follow-up results for patients who underwent therapy compared with healthy individuals showed that patients who underwent SCT showed marked improvements on all domains of the evaluation, much lower mortality rates, and complete absence of malignancy, compared with patients enrolled in SMT. The authors clearly showed a significant advantage of SCT in chronic liver disease patients compared with SMT.