Liver cancer in HIV. Disclosures (last 1 year): Educational sessions sponsored by: Abbvie, Gilead

Transcription

1 Liver cancer in HIV David Wong, MD Toronto Centre for Liver Disease TGH Immunodeficiency Clinic SMH Positive Care Clinic Disclosures (last 1 year): Educational sessions sponsored by: Abbvie, Gilead

2 Speaker disclosure Potential conflict Disclosure - if potential conflict of interest exists Direct financial interest in a company Investments in a company Membership on a company s Advisory Board Principal Investigator in a clinical trial sponsored by a company Research sponsored by a company ADDITIONAL TEXT EXAMPLE Consultant fees paid by a company None None None Gilead: Harvoni for HCV-HIV, Tenofovir for HBV Abbvie: Holkira for HCV (long term follow-up) None None

3 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

4 Background Hepatoma is hepatocellular carcinoma Main risks Cirrhosis (must survive long enough) Fatty liver: alcohol, diabetes (metabolic syndrome) Viral: HBV, HCV Chronic HBV infection

5 Cancer in Ontario

6 Natural history of chronic liver disease

7 Liver disease trends in Ontario Alcohol still common? Fatty liver increasing Cardiovascular mortality still higher Hepatitis B treatable since Liver failure uncommon Treatment decreases (delays) risk Hepatitis C treatable since 2014 Cure of infection decreases risk in cirrhotics

8 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

9 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

10 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

11 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)

12 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

13 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

14 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

15 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)

16 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