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标题: 在老年乙肝患者中，建议进行癌症监测 [打印本页]

作者: StephenW 时间: 2018-11-27 20:46 标题: 在老年乙肝患者中，建议进行癌症监测

In Older Hep B Patients, Carcinoma Surveillance Is Advised

Laird Harrison

November 15, 2018

SAN FRANCISCO — Surveillance for hepatocellular carcinoma (HCC) should continue in patients older than 50 years, even after they have undergone 5 years of therapy for chronic hepatitis B, according to an analysis of the PAGE-B cohort.
But the risk for the cancer is low enough in younger patients — except for those with cirrhosis — that surveillance might not be warranted, said George Papatheodoridis, MD, PhD, from Athens University Medical School in Greece.
"It will save monitoring in some patients," he told Medscape Medical News.
Long-term monotherapy with entecavir (Baraclude, Bristol-Myers Squibb) or tenofovir disoproxil fumarate (Viread, Gilead) suppresses the hepatitis B virus and improves liver lesions, so the survival rate in patients without compensated cirrhosis is comparable to that in the general population, Papatheodoridis explained here at The Liver Meeting 2018.

Still, the risk for HCC is significantly elevated in patients with chronic hepatitis B. It is the only factor that affects liver-related mortality in this population. Most data available on HCC risk in such patients come from studies with an average duration of less than 5 years.
So Papatheodoridis and his colleagues analyzed the need for HCC surveillance in their 10-center PAGE-B cohort.
They identified 1427 patients with no hepatitis C, hepatitis D, or HIV, who had not undergone liver transplantation, and who had a follow-up of more than 5 years.
At baseline, average age was 51 years, 77% of the cohort was male, 6% reported a history of alcohol abuse, and 8% had diabetes mellitus. In addition, 27% had cirrhosis diagnosed with biopsy. The cirrhosis status of 2% of the cohort was unknown.
After 5 years of therapy, patients underwent transient elastography (FibroScan, EchoSens), a type of ultrasound, to assess cirrhosis. With a liver stiffness cutoff of 12 kPa, 8.4% of the study population was determined to have cirrhosis.
The team used ultrasound and alpha-fetoprotein levels at least every 6 months to screen for HCC. Patients were followed for up to 12 years (mean, 8.4 years) and, during the follow-up period, 2.3% of patients were diagnosed with HCC.
On Cox regression analysis, there was a significant association between the development of HCC and cirrhosis at baseline, high baseline alanine aminotransferase levels, low baseline platelet counts, detectable hepatitis B DNA at baseline, nucleos(t)ide analogs before entecavir or tenofovir therapy, starting hepatitis B therapy after the age of 50 years, being older than 50 years after 5 years of therapy, and liver stiffness at year 5.
There was no significant association between risk for HCC and sex, body mass index, or hepatitis B e-antigen status.

On multivariable Cox regression analysis, only age, cirrhosis at baseline, and liver stiffness of at least 12 kPa at year 5 remained independently associated with the development of HCC in years 5 to 13.
But the liver stiffness measurement was ambiguous. The difference in HCC risk between patients with no cirrhosis at baseline and those with liver stiffness below 12 kPa at 5 years was significant (P = 0.001).
However, there was no significant difference between patients with liver stiffness above or below the cutoff of 12 kPa (P = .657).

Table. Risks for HCC During the Follow-up Period
Measure	Year 6, %	Year 8, %	Year 10, %
No cirrhosis at baseline (n = 658)	0.6	1.7	2.0
Liver stiffness <12 kPa at year 5 (n = 206)	1.0	5.1	8.0
Liver stiffness ≥12 kPa at year 5 (n = 66)	1.5	7.0	7.0

Only one patient younger than 50 developed HCC. After the first 5 years of drug therapy, HCC seems to develop almost exclusively in patients older than 50 years, Papatheodoridis and his colleagues conclude.
Platelets are not useful for excluding patients from HCC surveillance after 5 years of therapy because the risk for HCC in all the subgroups was more than 0.2%, "the threshold for cost-effective," the researchers write in their abstract.
Surveillance should continue in all patients who are at least 50 years old after 5 years of therapy, they recommend. The risk associated with liver stiffness measured by transient elastography needs further study, but surveillance should continue "probably in the few cirrhotics" who are younger than 50 years.
The surveillance can be done with ultrasound, with alpha-fetoprotein levels as an optional addition.
Results from this analysis of patients from Greece, Germany, Italy, the Netherlands, Spain, and Turkey should be confirmed in other cohorts, Papatheodoridis pointed out.
The ambiguity of the transient elastography finding prompted questions from the audience. One person wondered if some aspect of liver damage other than stiffness persists after drug treatment. Another suggested that MRI would be more accurate for the detection of cirrhosis.
The correlation between cancer and baseline cirrhosis stood out for session moderator Kimberly Brown, MD, from the Henry Ford Health System in Detroit.
"What is important is that the risk continued even in patients whose cirrhosis improved once they were on treatment," she told Medscape Medical News. "This tells us that in patients on treatment for hepatitis B, we really need to screen both the older patients over time, regardless of the degree of their cirrhosis, and patients who had any indication of cirrhosis before starting treatment."
Papatheodoridis reports financial relationships with MSD, AbbVie, and Gilead. Brown reports financial relationships with Gilead, Merck, and Pfizer.
The Liver Meeting 2018: American Association for the Study of Liver Diseases (AASLD): Abstract 0017. Presented November 12, 2018.

作者: StephenW 时间: 2018-11-27 20:48

在老年乙肝患者中，建议进行癌症监测

莱尔德哈里森

2018年11月15日

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旧金山 - 根据对PAGE-B队列的分析，即使在他们接受了5年的慢性乙型肝炎治疗之后，对于50岁以上的患者仍应继续监测肝细胞癌（HCC）。

但希腊雅典大学医学院的医学博士George Papatheodoridis表示，年轻患者患癌症的风险足够低 - 除肝硬化患者外 - 可能无法进行监测。

“它将节省一些患者的监测，”他告诉Medscape医学新闻。

恩替卡韦（Baraclude，Bristol-Myers Squibb）或替诺福韦地索普西富马酸盐（Viread，Gilead）长期单药治疗可抑制乙型肝炎病毒并改善肝脏病变，因此无补偿性肝硬化患者的生存率与一般人群相当。，Papatheodoridis在2018年的肝脏会议上解释说。

然而，慢性乙型肝炎患者的HCC风险显着升高。这是影响该人群肝脏相关死亡率的唯一因素。大多数关于此类患者HCC风险的数据来自平均持续时间少于5年的研究。

因此，Papatheodoridis及其同事分析了他们在10个中心的PAGE-B队列中对HCC监测的需求。

他们确定了1427例没有接受过肝移植的丙型肝炎，丁型肝炎或艾滋病病毒的患者，他们的随访时间超过5年。

在基线时，平均年龄为51岁，77％的人群为男性，6％报告有酗酒史，8％有糖尿病。此外，27％有肝硬化被诊断为活检。 2％的肝硬化状态尚不清楚。

经过5年的治疗，患者接受了瞬时弹性成像（FibroScan，EchoSens），这是一种超声检查，用于评估肝硬化。肝脏硬度截止值为12 kPa时，8.4％的研究人群被确定患有肝硬化。

该团队至少每6个月使用超声和甲胎蛋白水平来筛查HCC。患者随访时间长达12年（平均8.4岁），在随访期间，2.3％的患者被诊断为HCC。

在Cox回归分析中，HCC与基线肝硬化，高基线丙氨酸氨基转移酶水平，低基线血小板计数，基线可检测的乙型肝炎DNA，恩替卡韦或替诺福韦治疗前的核苷（酸）类似物之间存在显着相关性， 50岁后开始接受乙型肝炎治疗，治疗5年后开始接受50岁以上治疗，第5年开始肝硬化。

HCC风险与性别，体重指数或乙型肝炎e抗原状态之间无显着相关性。

在多变量Cox回归分析中，只有年龄，基线肝硬化和第5年至少12 kPa的肝硬度仍然与5 - 13年的HCC发展独立相关。
但肝硬度测量结果不明确。基线时无肝硬化患者与5年时肝硬度低于12 kPa的患者HCC风险差异显着（P = 0.001）。

然而，肝硬度高于或低于12 kPa截止值的患者之间没有显着差异（P = .657）。
表。随访期间HCC的风险
衡量6年级，％8年级，％10年级，％
基线时没有肝硬化（n = 658）0.6 1.7 2.0
第5年肝硬度<12 kPa（n = 206）1.0 5.1 8.0
第5年肝硬度≥12kPa（n = 66）1.5 7.0 7.0

只有一名年龄小于50岁的患者发生了HCC。 Papatheodoridis及其同事总结说，在药物治疗的前5年后，HCC似乎几乎只发生在50岁以上的患者身上。

研究人员在他们的摘要中写道，血小板对于在治疗5年后排除HCC监测患者无效，因为所有亚组中HCC的风险均超过0.2％，“成本效益的门槛”。

他们建议，对于治疗5年后至少50岁的所有患者，应继续进行监测。通过瞬时弹性成像测量的与肝硬度相关的风险需要进一步研究，但监测应该继续“可能在少数50岁以下的少数肝硬化患者中”。

监测可以通过超声进行，甲胎蛋白水平作为可选的添加。

Papatheodoridis指出，来自希腊，德国，意大利，荷兰，西班牙和土耳其的患者的分析结果应该在其他队列中得到证实。

瞬态弹性成像的模糊性引发了观众的质疑。有人想知道药物治疗后肝硬化的某些方面是否会持续僵硬。另一位研究人员建议MRI对肝硬化的检测更准确。

癌症与基线肝硬化之间的相关性因会议主持人Kimberly Brown医学博士在底特律亨利福特健康系统中脱颖而出。

她告诉Medscape医学新闻说：“重要的是，即使在肝硬化患者接受治疗后，风险也会持续下去。” “这告诉我们，在接受乙型肝炎治疗的患者中，我们确实需要随着时间的推移筛查老年患者，无论他们的肝硬化程度如何，以及在开始治疗前有任何肝硬化迹象的患者。”

Papatheodoridis报告与MSD，AbbVie和Gilead的财务关系。布朗报告与吉利德，默克和辉瑞的财务关系。

2018年肝脏会议：美国肝病研究协会（AASLD）：摘要0017. 2018年11月12日。

作者: Newbegin 时间: 2018-11-28 12:04

学习了，50岁是一个分水岭

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