Liver cancer in HIV David Wong, MD Toronto Centre for Liver Disease - - PowerPoint PPT Presentation

David Wong, MD

Toronto Centre for Liver Disease TGH Immunodeficiency Clinic SMH Positive Care Clinic

www.torontoliver.ca www.facebook.com/torontoliver

Disclosures (last 1 year): Educational sessions sponsored by: Abbvie, Gilead

Liver cancer in HIV

Speaker disclosure

ADDITIONAL TEXT EXAMPLE

Potential conflict

Disclosure - if potential conflict of interest exists

Direct financial interest in a company None Investments in a company None Membership on a company’s Advisory Board None Principal Investigator in a clinical trial sponsored by a company Gilead: Harvoni for HCV-HIV, Tenofovir for HBV Abbvie: Holkira for HCV (long term follow-up) Research sponsored by a company None Consultant fees paid by a company None

Outline

• Identifying those at risk for liver cancer

– Cirrhosis (thrombocytopenia) – Chronic hepatitis B (HBsAg positive)

• Screening for liver cancer

– Who and how to screen

• Diagnosis and management

Background

• “Hepatoma” is hepatocellular carcinoma
• Main risks

– Cirrhosis (must survive long enough)

• Fatty liver: alcohol, diabetes (metabolic syndrome)
• Viral: HBV, HCV

– Chronic HBV infection

Cancer in Ontario

Natural history of chronic liver disease

Liver disease trends in Ontario

• Alcohol still common?
• Fatty liver increasing

– Cardiovascular mortality still higher

• Hepatitis B treatable since 2002-2006

– Liver failure uncommon – Treatment decreases (delays) risk

• Hepatitis C treatable since 2014

– Cure of infection decreases risk in cirrhotics

Who is at risk?

• Chronic hepatitis

– Abnormal liver enzymes > 6 months – Hepatitis: usually ALT > AST

• Ratio reverses in advanced cirrhosis
• Enzymes can be normal
• Chronic HBV infection

– HBsAg positive > 6 months

• NB NOT HBsAg negative, anti-HBc positive
• Cirrhosis  Liver failure

– Thrombocytopenia (Plts < 150)

Platelets INR Albumin Bilirubin

Earlier stage cirrhosis

• Non-invasive markers of liver fibrosis

– APRI (Platelets fall, AST rise) – FIB-4 (as above, add age and ALT) – Fibrotest (GGT rises, haptoglobin falls, bilirubin rises, a2-macroglobulin rises) – Fibroscan (liver stiffness increases)

• Liver biopsy

Screening

• Cost effective if risk is great enough

– >1.5% per year – True for untreated cirrhosis – Chronic HBV in Asians

• Male > 40 years old
• Female > 50 years old
• Risk significantly reduced for

– HBV cirrhosis where HBV suppressed – HCV cirrhosis where HCV eradicated

How to screen

• Worthwhile if you would treat cancer if found

– Good performance status/survival otherwise – Willing to have cancer treatment

• Ultrasound q6-12 monthly

– Looking for a new or growing nodule

• Serum AFP

– Better confirmation test like CEA

• Goes up with hepatitis flare (non-specific)
• Only elevated with large cancers (non-sensitive)

Confirmation of cancer > 1 cm

• Biopsy usually NOT

needed

• Contrast enhanced

imaging (US, CT, MRI)

– Arterial enhancement “Hypervascular” – Delayed washout

• Biopsy only if

concerning but not diagnostic by imaging

What to do with hepatoma

• Child Pugh

– A: 0 – B: 1 – C: 2

• Tumor morphology

– Uninodular <50%: 0 – Multinodular <50%: 1 – Masive > 50%: 2

• AFP

– <400: 0 – >400: 1

• Vascular invasion

– No: 0 – Yes: 1

Management

• If decompensated cirrhosis

– Transplant is only treatment for hepatoma – No role for cancer screening if not a transplant candidate

• Age > 70
• Recent other cancer (<5 years)
• Unable to stop drinking alcohol

Hepatoma treatment

• Curative

– Ablation if up to 3 lesions <2.5 cm – Resection

• Relatively safe if platelets > 100, liver function normal

– Transplant

• Organ availability is limiting
• Palliative

– TACE chemotherapy – Sorafenib – Radiation – Experimental protocols (immune break inhibitors)

Summary

• Liver cancer is increasing because patients are

surviving long enough to have cirrhosis for a long time

• Liver cancer risk is decreased if the primary liver

disease is treated

– Investigate all with chronic hepatitis (ALT/AST) – Screen for HBV (HBsAg) and HCV (anti-HCV) – Tests for cirrhosis

• Screening ultrasound is cost effective if risk is >1.5%

per year

– Untreated cirrhosis – Untreated HBV infection older individuals