20131222 tasl hbv pre-s deletion mutants and hcc outcomes
TRANSCRIPT
B型肝炎病毒表面前區剔除性突變
與抗病毒藥物,對於肝細胞癌患者
接受切除手術後,腫瘤復發之影響
蘇建維1,2,3 邱昱維4 蔡宜璇1 鄧睿敦1
周嘉揚2,5 洪宏緒1,6 霍德義3,7 吳肇卿1,4
1陽明大學醫學院 臨床醫學研究所2陽明大學醫學院 醫學系
3台北榮民總醫院 內科部胃腸科4台北榮民總醫院 醫學研究部轉譯研究科
5台北榮民總醫院 外科部一般外科6振興醫院 內科部胃腸肝膽科
7陽明大學醫學院 藥理學研究所
HBV genotype, precore and BCP mutants and HCC
305.6
785.8
955.5
269.4358.7
1149.2
0
200
400
600
800
1000
1200
1400
Genotype B
Genotype C
Precore wild
Precore Mutant
BCP wild
BCP mutant
Incidence rate per 100,000 person-years
Yang HI, et al. JNCI 2008;100:1134-43
Immune epitopes and functional domains within the HBV pre-S region
Su IJ, et al. J Gastroenterol Hepatol 2008Kao JH Liver Int 2012
Combined risk of developing HCC associated with HBV mutants and HCV genotype
Hung CH, Chen CH, Lee CM, et al. Intervirology 2013;56:316-24
Schematic representation of factors that influence the progression of HBV-related liver disease
Host Factors
Age> 40 years
Gender: Male> Female
Immune status
Viral FactorsGenotype: C> B; D>A
Viral load:> 104
copies/mL
Genome Mutations: pre-S deletion, T1762/A1764
Environmental factors
Alcohol
Smoking
Aflatoxin exposure
Concurrent HCV, HDV, HIV infection
Liaw YF, Factors influencing liver disease progression in chronic hepatitis B. Liver Int 2006; 26: 23-29
GGH predicts prognosis of HCC patients after resection surgery
Tsai HW, Su IJ, et al. Cancer 2011; 117:2951-60
GGH predict prognosis of HCC patients after resection surgery
Tsai HW, Su IJ, et al. Cancer 2011; 117:2951-60
GGH predict prognosis of HCC patients after resection surgery
Tsai HW, Su IJ, et al. Cancer 2011; 117:2951-60
Small pre-S deletion predict poor prognosis after resection for HCC
Yeh CT, et al. Hepatology 2010;52:1922-33
178 patients from non-tumor part of liver specimens
Small pre-S deletion predict poor prognosis after resection surgery for HCC
Yeh CT, et al. Hepatology 2010;52:1922-33
Disease-free survival Overall Survival
Lack of Association Between HBVPre-S Mutations and Recurrence After Surgical
Resection in HCC
Heo NY, Lee HC, Park YK, et al. J Med Virol 2013; 85:589-96
All were genotype C19 (29.7%) of the 64 patients had pre-S deletion
Lack of association between HBVpre-S mutations and recurrence after resection in HCC
Heo NY, Lee HC, Park YK, et al. J Med Virol 2013; 85:589-96
Heo NY, Lee HC, Park YK, et al. J Med Virol 2013; 85:589-96
Recurrence-free survival Overall Survival
Lack of association between HBVpre-S mutations and recurrence after resection in HCC
Heo NY, Lee HC, Park YK, et al. J Med Virol 2013; 85:589-96
Lack of association between HBVpre-S mutations and recurrence after resection in HCC
Pre-S deletion mutants are associated with HCC development.
However, the prognostic value of pre-S deletion mutants in HCC patients after
curative therapies is still unclear.
Hepatitis B Viral Load, Pre-S Deletion Mutations and Anti-viral Therapy Predict
Post-operative Recurrence of Hepatocellular Carcinoma
PLoS ONE 2013;8(6):e66457
Materials and Methods
• From 1989 to 2007, 333 patients with HBV-related HCC who underwent resection surgery at Taipei Veterans General Hospital were enrolled.
• A total of 62 patients received antiviral therapy for HBV infection after resection, while the remaining 271 patients did not take antiviral therapy during the follow-up period.
• All serum samples of enrolled patients were tested for HBV DNA levels and genotype; and clonal analysis of pre-S regions were performed in 216 patients.
• After a median follow-up of 45.9 months, 165 patients died and 208 patients had HCC recurrence after resection. The 5-year overall survival and recurrence-free survival rates were 55.4% and 35.3%, respectively.
Characterization of HBV related HCC patients between genotype B and genotype C
All patients
(n= 333)
B
(n=174)
C
(n=139)
P
Patient Demographics (continuous variables are expressed as median; 25 and 75 percentiles)
Age (years) 56; 47-67 56; 44-68.3 57; 48-64 0.692
Sex (M/F) (%) 271/42 (86.6%/13.4%) 153/21 (87.9%/12.1%) 118/21 (84.9%/15.1%) 0.537
HCC family history
(yes/no) (%)
71/235
(23.2%/76.8%)
32/126
(20.3%/79.7%)
36/93
(27.9%/72.1%)
0.168
Albumin (g/dL) 4.0; 3.8-4.3 4.1; 3.9-4.4 3.9; 3.7-4.2 <0.001
Total bilirubin (mg/dL) 0.9; 0.7-1.2 0.8; 0.7-1.1 0.9; 0.7-1.2 0.715
ALT (U/L) 42; 28-66 40; 26-61.5 46; 31.8-73.3 0.017
ICG-15R (%) 10.0; 6.0-16.0 10.0; 6.0-15.0 12; 7-17.5 0.024
Platelet (/mm3) 162000; 120500-
212500
167500; 132500-
215750
143000; 104000-
200000
0.023
PT INR 1.01; 0.95-1.07 1.00; 0.95-1.05 1.02; 0.96-1.13 0.011
Characterization of HBV related HCC patients between genotype B and genotype C
All patients
(n= 333)
B
(n=174)
C
(n=139)
P
Tumor factors (continuous variables are expressed as median; 25 and 75 percentiles)
Tumor size (cm) 4.0; 2.5-6.8 4.1; 2.5-6.7 3.5; 2.5-6.3 0.975
Multinodularity (%) 141/191 (42.3%/57.7%) 74/100 (42.5%/57.5%) 60/79 (43.2%/56.8%) 1.000
Macroscopic venous invasion (%) 61/271 (18.4%/81.6%) 36/138(20.7%/79.3%) 20/118(14.5%/85.5%) 0.205
AFP (ng/ml) 45.5; 7.4-974.5 31.3; 7.0-996.5 51.1; 8.2-714.8 0.146
Histo-pathological findings
Cirrhosis (yes/no) (%) 143/180 (44.3%/55.7%) 58/108 (34.9%/65.1%) 76/61 (55.5%/44.5%) 0.001
Edmondson grading (I-II/III-IV)(%) 214/108 (66.5%/33.5%) 117/50 (70.1%/29.9%) 87/49 (64.0%/36.0%) 0.317
Microscopic venous invasion (%) 221/111 (66.6%/33.4%) 117/57 (67.2%/32.8%) 92/46 (66.7%/33.3%) 1.000
Characterization of HBV related HCC patients between genotype B and genotype C
All patients
(n= 333)
B
(n=174)
C
(n=139)
P
Viral factors
HBVDNA(copies/mL) (median;
25 and 75 percentiles)
3.90 x 105;
1.73 x 104-7.64 x 106
3.21 x 105;
2.24 x 104-4.17 x 106
1.76 x 105;
2.45 x 104-1.39 x 106
0.390
HBsAg (IU/mL) (median; 25
and 75 percentiles)
830.0; 287.5-1830.0 935.0; 400.5-1781.3 897.0; 200.8-1959.4 0.241
Pre-core mutation (G1896A)
(Y/N) (%)
194/102 (65.5%/34.5%) 119/46 (72.1%/27.9%) 74/55 (57.4%/42.6%) 0.012
BCP (A1762T, G1764A)
mutation (Y/N) (%)
209/86 (70.8%/29.2%) 96/69 (58.2%/41.8%) 112/16 (87.5%/12.5%) <0.001
Pre-S deletion (yes/no) (%) 73/85 (46.2%/53.8%) 33/62 (34.7%/65.3%) 40/22 (64.5%/35.5%) <0.001
Antiviral therapy (Y/N) (%) 40/293 (12.0%/88.0%) 26/148 (14.9%/85.1%) 10/129 (7.2%/92.8%) 0.067
Univariate analysis of factors associated with overall survival after resection for hepatocellular carcinoma.
(all patients)
Variable Number Median survival months (95% CI) Hazard ratio (95% CI) P
Age > 60 / 60 y/o 131/201 50.6(41.0-60.2)/115.1(78.9-151.3) 1.743 (1.283-2.367) <0.001
Sex Female/Male 45/287 128.3(25.7-230.9)/70.4(53.7-87.1) 0.690(0.422-1.126) 0.137
Albumin 4 / > 4 g/dL 165/163 46.1(36.0-56.2)/125.9(80.4-171.4) 1.843(1.345-2.526) <0.001
Bilirubin > 1.6 / 1.6 mg/dL 20/312 81.9(46.3-117.5)/71.2(48.0-94.4) 0.855(0.450-1.623) 0.631
ALT >40 / 40 U/L 178/154 70.4(52.0-88.8)/79.7(42.8-116.6) 1.087(0.799-1.479) 0.594
ALK-P >100 / 100 U/L 132/199 41.2(26.1-56.3)/100.9(73.1-128.7) 1.892(1.392-2.571) <0.001
GGT >60 / 60 U/L 131/197 46.7(35.1-58.3)/113.5(92.6-134.4) 1.843(1.356-2.506) <0.001
Platelet 105 / > 105 /mm3 51/262 60.3(34.9-85.7)/74.2(45.5-102.9) 1.149(0.776-1.702) 0.488
ICG-15R > 10% / 10% 160/170 52.3(34.2-70.4)/120.9(80.1-161.7) 1.707(1.250-2.330) 0.001
MELD ≧8/<8 136/190 57.5(37.4-77.6)/94.5(67.4-121.6) 1.405(1.032-1.914) 0.013
Univariate analysis of factors associated with overall survival after resection for hepatocellular carcinoma.
(all patients)
Variable Number Median survival months
(95% CI)
Hazard ratio
(95% CI)
P
HBV genotype C/B 138/174 72.8(52.2-93.4)/
69.9(23.6-116.2)
1.120
(0.821-1.529)
0.475
HBV DNA >106 / 106 cp/ml 136/184 75.1(55.8-94.4)/
70.4(29.6-111.2)
0.980
(0.715-1.344)
0.901
HBsAg > 1000 / 1000 IU/mL 121/157 79.7(45.1-114.3)/
100.0(64.0-136.0)
1.142
(0.803-1.624)
0.459
Precore mutation Y/N 193/102 94.5(61.6-127.4)/
54.5(33.7-75.3)
0.752
(0.544-1.040)
0.085
A1762T/G1764A mutation Y/N 209/85 71.2(56.8-85.6)/
70.9(0-165.9)
1.040
(0.722-1.499)
0.833
Antiviral therapy (N/Y) 62/271 54.5(40.0-69.0)/
NA
5.938
(2.915-12.094)
<0.001
Univariate analysis of factors associated with overall survival after resection for hepatocellular carcinoma.
(all patients)
Variable Number Median survival months (95% CI) Hazard ratio (95% CI) P
Tumor size > 5cm / 5cm 122/210 37.5(22.6-52.4)/100.0(68.0-132.0) 2.001 (1.472-2.721) <0.001
Multinodularity Y/N 141/191 45.7(33.6-57.8)/119.8(97.9-141.7) 2.182 (1.603-2.972) <0.001
Macroscopic venous invasion
Y/N
61/271 16.8(0-36.5)/94.5(67.3-121.7) 2.809 (1.976-3.984) <0.001
Cut margin 1cm/ >1cm 223/108 60.3(45.9-74.7)/113.5(89.3-137.7) 1.520 (1.079-2.141) 0.017
AFP >20 / 20 ng/ml 192/136 69.7(48.1-91.3)/81.9(48.4-115.4) 1.308 (0.951-1.799) 0.099
Microscopic venous invasion
Y/N
221/110 52.3(40.6-64.0)/119.8(103.7-135.9) 2.203 (1.527-3.185) <0.001
Cirrhosis on non-tumor part Y/N 143/179 54.2(40.9-67.5)/122.5(82.9-162.1) 1.706 (1.248-2.331) 0.001
Edmondson stage III or IV/ I or II 214/108 79.9(54.0-105.8)/64.0(38.3-89.7) 1.369 (0.997-1.879) 0.052
Multivariate analysis of factors associated with overall survival after resection for HCC (all patients)
Variable Hazard ratio
(95% confidence interval)
Standard error P
ICG-15R > 10% 1.574(1.122-2.208) 0.173 0.009
ALK-P >100 U/L 1.762(1.267-2.450) 0.168 0.001
Macroscopic venous
invasion
2.326(1.580-3.425) 0.197 <0.001
Microscopic venous
invasion
1.848(1.225-2.786) 0.209 0.003
Without antiviral
therapy
8.275(2.631-26.023) 0.585 <0.001
The impact of anti-viral therapy on recurrence stratified by viral factors
HBV DNA levels
P< 0.001 P=0.038
The impact of anti-viral therapy on recurrence stratified by viral factors
Serum HBsAg levels
P= 0.001 P= 0.037
The effect of anti-viral therapy in decreasingrecurrence is irrespective of viral load
Impact of antiviral therapy on prognosis of HBV-related HCC after resection
Chan ACY, et al. Arch Surg 2011;146:675-81
AJCC stage I and II
AJCC stage III
Overall survival Disease-free survival
The effect of anti-viral therapy in improving overall survival is more apparent in early stage HCC
Multivariate analysis of factors associated with recurrence after resection for HCC (all patients)
Variable Hazard ratio
(95% confidence interval)
Standard error P
GGT >60 U/L 1.628 (1.210-2.190) 0.151 0.001
ICG-15 > 10% 1.386 (1.036-1.854) 0.148 0.028
Without antiviral therapy 2.296 (1.451-3.632) 0.234 <0.001
Macroscopic venous invasion 2.375(1.650-3.425) 0.186 <0.001
Microscopic venous invasion 1.499(1.080-2.083) 0.167 0.016
Strategy for Preventing HBV-HCC
Primary prevention
• HBV vaccination
Secondary prevention
• Adequate antiviral therapy
• Close surveillance (sonography and AFP)
Tertiary Prevention
• Adjuvant anti-tumor therapy (such as target therapy) for reducing early recurrence
• Antiviral therapy for improving liver functional reserve and reducing late recurrence
Summary
• Anti-viral therapy could improve the post-operativeprognosis both in terms of overall survival andrecurrence in patients with early stage HCC, but theeffect was less significant in those with BCLC stage C.
• As anti-viral therapy might confound the impact ofviral factors, to eliminate this bias, 62 patients whoreceived anti-viral therapy after resection surgerywere excluded and the remaining 271 patients werefurther analyzed for prognostic factors.
Multivariate analysis of factors associated with overall survival and recurrence after resection for HCC (without
antiviral therapy)
Variable HR (95% CI) Standard error P
Overall survivalICG-15 > 10% 1.618 (1.142-2.292) 0.178 0.007
ALK-P >100 U/L 1.441 (1.035-2.006) 0.169 0.031
Tumor size > 5 cm 1.602 (1.127-2.276) 0.179 0.009
Macroscopic venous invasion 2.155 (1.462-3.174) 0.198 <0.001
Microscopic venous invasion 1.842 (1.209-2.801) 0.214 0.004
Cirrhosis on non-tumor part 1.486 (1.043-2.116) 0.180 0.028
RecurrenceHBV DNA >106 copies/mL 1.428 (1.047-1.947) 0.158 0.024
GGT >60 U/L 1.700 (1.239-2.331) 0.194 0.001
Macroscopic venous invasion 2.387 (1.634-3.497) 0.180 <0.001
Microscopic venous invasion 1.594 (1.121-2.273) 0.195 0.010
Ongoing viral replication is a crucial predictor of post-operative HCC recurrence, anti-viral therapy can reduce recurrence and improve
prognosis.
Characterization of HBV related HCC patients with and without pre-S deletion (n=216)
Without Pre-S deletion(n=143)
With Pre-S deletion (n=73)
P
Patient Demographics
Age (years) 58; 46-69 54; 46-64 0.500
Sex (male/female) (%) 123/20 (86/0%/14.0%) 65/8 (89.0%/11.0%) 0.680
HCC family history (yes/no) (%)
28/100 (21.9%/78.1%) 20/47 (29.9%/70.1%) 0.292
Albumin (g/dL) 4.1;3.9-4.4 4.0; 3.7-4.2 0.018
Total bilirubin (mg/dL) 0.9; 0.7-1.2 0.9; 0.7-1.3 0.847
ALT (U/L) 42; 27.5-65.6 49; 39-74 0.084
ICG-15R (%) 11; 6-16 10; 7-17 0.735
Platelet (/mm3) 156000; 125000-199000 148000; 98000-209000 0.849
PT INR 1.01; 0.96-1.06 1.00; 0.94-1.12 0.571
MELD 7.7; 6.6-8.6 7.9; 6.9-9.3 0.796
15: pre-S143: pre-S215: pre-S1+ pre-S2
Characterization of HBV related HCC patients with and without pre-S deletion (n=216)
Without Pre-S deletion(n=143)
With Pre-S deletion (n=73)
P
Tumor factors
Tumor size (cm) 3.4; 2.5-6.0 3.0; 2.1-6.0 0.191
Multi-nodularity/single tumor (%)
57/86 (39.9%/60.1%) 25/48 (34.2%/65.8%) 0.512
Macroscopic venous invasion (yes/no) (%)
21/121 (14.8%/85.2%) 12/61 (16.4%/83.6%) 0.906
AFP (ng/ml) 20.8; 6.7-752.3 50.6; 12.1-803.0 0.343
Cut margin ≤1/>1 cm (%) 101/42 (70.6%/29.4%) 45/27 (62.5%/37.5%) 0.294
Cirrhosis (yes/no) (%) 51/86 (37.2%/62.8%) 40/30 (57.1%/42.9%) 0.010
Edmondson grading (I-II/III-IV) (%)
47/91 (34.1%/65.9%) 18/53 (25.4%/74.6%) 0.258
Microscopic venous invasion (yes/no) (%)
93/49 (65.5%/34.5%) 47/26 (64.4%/35.6%) 0.992
BCLC (A/B/C) (%) 84/40/14(59.6%/28.4%/12.1%)
45/16/11(62.5%/22.2%/15.3%)
0.566
Characterization of HBV related HCC patients with and without pre-S deletion (n=216)
Without Pre-S deletion(n=143)
With Pre-S deletion (n=73)
P
Viral factors
HBVDNA(copies/mL)* 4.85 x 105;3.67 x 104-1.08 x 107
1.61x 106; 9.95 x 104-1.51 x 107
0.055
HBsAg (IU/mL)* 896.3; 339.5-1732.4 1127.5; 405-2101 0.297
Genotype B/C (%) 98/44 (69.0%/31.0%) 33/40 (45.2%/54.8%) 0.001
Pre-core (G1896A) mutation (yes/no) (%)*
88/42 (67.7%/32.3%) 40/28 (58.8%/41.2%) 0.279
BCP (A1762T, G1764A) mutation (yes/no) (%)*
83/47 (63.8%/36.2%) 52/16 (76.5%/23.5%) 0.099
Multivariate analysis of factors associated with overall survival and recurrence after resection for HCC (without
antiviral therapy)
Variable HR (95% CI) Standard error P
Overall survivalAge >60 years 2.035 (1.288-3.215) 0.233 0.002
Alk-P >100 U/L 2.288 (1.451-3.606) 0.232 <0.001
Macroscopic venous invasion 2.967 (1.730-5.102) 0.276 <0.001
Microscopic venous invasion 1.825 (1.046-3.185) 0.284 0.034
G1896A mutation 0.598 (0.382-0.937) 0.229 0.025
RecurrenceMulti-nodularity 1.693 (1.115-2.571) 0.213 0.013
Macroscopic venous invasion 2.415 (1.418-4.098) 0.271 0.001
Cirrhosis 1.544 (1.047-2.279) 0.198 0.029
Edmondson stage III or IV 1.526 (1.029-2.263) 0.201 0.036
Pre-S deletion 1.564 (1.057-2.314) 0.200 0.025
Pre-S deletion and post-operative recurrence stratified by serum HBVDNA and HBsAg levels
P=0.028P=0.047
P=0.926 P=0.253
The impact of pre-S deletion mutants on recurrence for patients receiving anti-viral therapy
P=0.161
hepatocarcinogenesis and tumor recurrence induced by pre-S deletion mutants may be based on active HBV viral replication, the accumulation
of oxidative stress, and subsequent chromosomal instability
Conclusion
• On-going viral replication and the presence of pre-S deletion mutants are both crucial predictors of post-operative HCC recurrence.
• Hepatocarcinogenesis and tumor recurrence induced by pre-S deletion mutants may be based on active HBV viral replication, the accumulation of oxidative stress, and subsequent chromosomal instability
• Antiviral therapy may improve post-operative outcomes, especially in early stage HCC.