Characteristics and Prognosis of Hepatocellular Carcinoma in Multi-Transfused Patients with β-Thalassemia. Experience of a Single Tertiary Center
1 1st Department of Internal Medicine, 417 Army Share Fund Hospital of Athens.
2 2nd Department of Medicine, National and Kapodistrian University of Athens, Medical School, Hippokration General Hospital of Athens.
3 2nd and 1st Department of Radiology, National and Kapodistrian University of Athens, Medical School, Evgenidion Hospital of Athens.
Received: September 9, 2019
Accepted: February 4, 2020
Mediterr J Hematol Infect Dis 2020, 12(1): e2020013 DOI 10.4084/MJHID.2020.013
| This is an Open Access article distributed
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The incidence of hepatocellular carcinoma (HCC) in patients with
transfusion dependent thalassemia (TDT) has been increasing, where
viral hepatitis and iron overload are the two established HCC risk
factors. The aim of this study was to investigate the etiological
factors of HCC development and to evaluate the possible factors
associated with survival in our cohort of TDT patients with HCC.
Both alpha- and beta-thalassemia are more prevalent in tropical and subtropical regions of the world. The southern regions of Europe, such as Italy and Greece, are the most likely areas to be affected in Europe. Greece, a country of approximately 11 million people, has a mean frequency of thalassaemia carriers at 7%.
The role of viral hepatitis as a risk factor for hepatocarcinoma is essential in thalassemia, mainly in older patients, since the risk of viral transmission through blood transfusion was significantly reduced after the 1990s with the identification of the HCV virus and the universal screening of blood donors. The estimation of the current prevalence of Hepatitis C in Greece ranges from 0.5% to 2% according to the population studied, while the prevalence of HBsAg was 0.84% in a 6-year blood donor based study in Athens.[4,5] HBV-induced hepatocarcinogenesis is a multifactorial process that involves the presence of chronic hepatitis and cirrhosis and also the direct role of hepatitis B virus (HBV), development of HCC in the absence of cirrhosis, mainly through HBV-DNA integration into the host DNA which alters the function of endogenous genes or induces chromosomal instability. On the other hand, HCV-induced hepatocarcinogenesis of HCC is a gradual process that relates to chronic hepatitis and the duration of disease leading to liver cirrhosis.[7-10] Furthermore, the risk of HCC is greatly reduced in HCV cirrhotic patients who obtained a sustained virological response (SVR) after HCV treatment but is not eliminated.[11,12]
Both the incidence and the etiology of HCC changed over the last 25 years. In a recently published study performed in Crete island, authors indicate a rose from 6.0 new cases per 100,000 inhabitants in the first five-year period (1990-1994) to 16.8 in the last five years (2010-2014). The change was mostly attributable to a gradual increase in the incidence of HB, alcohol and non-alcoholic fatty liver disease (NAFLD) related cases, especially during the last decade.
The hepatocarcinogenicity of iron seems to be a very complex phenomenon. It is well established that patients with hereditary hemochromatosis have a risk of developing HCC even in the absence of cirrhosis. Even more, several reports have described the development of HCC in non-cirrhotic patients with thalassemia syndromes who were negative for HBV and HCV but had a hepatic iron overload. The primary hypothesis is that free iron, even in the absence of cirrhosis, is hepatocarcinogenic due to the generation of reactive oxygen species (ROS), which causes peroxidation of membrane fatty acids that impair protein synthesis and disrupt DNA synthesis.
Data concerning etiological factors and treatment outcomes of HCC appear to be lacking in patients with transfusion dependent thalassemia (TDT). The aim of this study was to investigate the etiological factors of HCC development and to evaluate the possible factors associated with survival among Greek patients with TDT and HCC.
Patients and Methods
Τhe average of the last four measurements before the diagnosis of HCC has been used to represent the levels of ferritin and hemoglobin for the purpose of our analysis. All included patients in the study had serum ferritin levels less than 1,000 ng/ml. Hepatic magnetic resonance imaging (MRI) is now considered the gold standard method for estimating and monitoring liver iron concentration (LIC) in these patients. Thus, liver iron overload has been assessed by the signal-intensity-ratio MRI (Rennes University algorithm) at the time of HCC diagnosis.[16,17] Patients with LIC values ≤40μmolFe/g were considered as normal, those with LIC values between 40 and ≤100 μmolFe/g as having mild hemosiderosis, those with LIC values between 100 and ≤200 μmolFe/g as having moderate hemosiderosis and those with LIC values above 200 μmolFe/g as having severe iron overload. Liver cirrhosis has been diagnosed using imaging methods (computed tomography scan or liver ultrasound), while in four of them (9.5%) has been documented by liver biopsy. The diagnosis of HCC was done by magnetic resonance imaging (MRI) with contrast (3 phase) and was confirmed by guided liver biopsy in uncertain by MRI cases. All patients were assessed using Barcelona Clinic Liver Cancer (BCLC) grading system and were classified as very early or early stage (0-A), intermediate stage (B), and as advanced or terminal stage (C-D). The very early stage (BCLC 0) is defined as the presence of a single nodule < 2 cm in diameter in patients with well-preserved liver function (Child-Pugh A). The early stage (BCLC A) corresponds to patients with one nodule < 5 cm or up to three nodules each < 3 cm. Patients with BCLC stages 0 and A are candidates for potentially curative treatment options such as surgical resection, liver transplantation, or local radiofrequency ablation (RFA). The intermediate stage (BCLC B) includes asymptomatic patients with large or multifocal tumors. The advanced stage (BCLC C) concerns patients with cancer-related symptoms, macrovascular invasion, or extrahepatic spread. Patients with BCLC B and C are treated with palliative approaches, such as transarterial chemoembolization (TACE) or systemic therapy with sorafenib. Patients in the terminal stage (BCLC D) receive best supportive care. The study has been performed according to the World Medical Association Declaration of Helsinki and has been approved by the hospital ethics committee. All patients were informed and consent to access their confidential data from the hospital’s medical records.
Statistical analysis. All data were analyzed using the statistical package MedCalc (version 18.11). Statistical analysis was performed using a t-test for comparisons of continuous variables between groups and corrected chi-squared test for comparisons of qualitative data. A two-tailed p value <0.05 was considered to be statistically significant. The survival time for each patient, in terms of months, was defined as the interval between the dates of HCC diagnosis and the date of death or the end of the study. Cumulative survival rates were estimated using the Kaplan-Meier method, while cox proportional hazards model was also used to identify risk factors relating to survival.
Out of 42 patients, 33 (78.5%) were anti-HCV positive. Most of them 25/42 (59.5%) were HCV-RNA positive within the last 10 years. The rest of the anti-HCV positive patients (8/42) were always HCV-RNA negative indicative of spontaneous viral clearance after exposure to the virus. All viraemic patients have been treated either with Pegylated - interferon alpha (Peg-IFN) ± ribavirin (RBV) [8/25, (32%)] or with the new interferon-free, direct acting antivirals (DAAs) regimens [17/25, (68%)]. All patients had achieved sustained virological response (SVR) at least 12 months before HCC diagnosis.
Regarding HBV infection, none of our patients was HBsAg positive. Thus, no one had received anti-viral treatment. However, 7 patients (16.5%) had serological evidence of resolved HBV infection [HBsAg(-)/anti-HBc(+)/anti-HBs(+)] without prior anti-HBV treatment. All of these patients had a history of acute HBV infection, and finally, they have achieved HBsAg clearance.
The mean LIC values were 48.6±29.5 μmolFe/g. More than half of our patients (55%) had average LIC values, 18 patients (43%) were classified as having mild hemosiderosis and only one patient (2%) has been classified as having moderate hemosiderosis.
αFP levels have been assessed in all patients and were ≤100 ng/ml in 26 of them (62%).
The tumor has been diagnosed as multifocal (≥3) in 25 patients (59.5%), while those with maximum diameter ≥5cm have been diagnosed in 18 patients (43%). According to the BCLC grading system, patients were classified as 0-A: 12/42 (28.5%), B: 24/42 (57%) and as C-D: 6 patients (14.5%).
HCC has been treated with TACE or RFA in 33 patients (78.5%) while the rest 9 patients were treated with sorafenib. Two patients with very early stage and no other contraindication underwent surgical excision but eventually, they have been treated with loco-regional therapies due to HCC relapse in the first six months. These two patients have been included in TACE/RFA group.
Overall, 28 patients (66.5) have eventually died due to HCC, with a median survival time of 6 months (2-60), while a median survival time of 60 months (6-96) has been observed in still living patients at the end of the study (Table 1).
|Table 1. Baseline characteristics of 42 patients with thalassemia major and HCC.|
The overall Kaplan-Meier survival curve of the patients is shown in figure 1. In order to reveal possible risk factors relating to survival, we used the cox proportional hazard model adjusted for age (Table 2). BCLC stages C and D were associated with poor survival (HR: 5.4179, 95% CI: 1.4936-19.6531, p=0.0102) (Figure 2).
|Figure 1. Overall Kaplan-Meier survival curve.|
|Table 2. Prognostic factors affecting survival using the Cox proportional hazard model.|
|Figure 2. Kaplan-Meier survival curve according BCLC staging.|
Both chronic viral hepatitis B and C and related cirrhosis remain important risk factors for the development of HCC. In our study 7 patients had serological markers of past HBV infection [HBsAg
(-)/anti-HBc(+)/anti-HBs(+)] but all of them were cirrhotics. Theoretically, the hepatocarcinogenicity of HBV remains in patients with resolved HBV infection (spontaneous seroconversion of HBsAg) mainly through HBV-DNA integration into the host genome. However, the risk of HCC is significantly lower in HBsAg negative than in HBsAg positive patients and the presence of liver cirrhosis is the dominant risk factor for hepatocarcinogenesis. With respect to chronic HCV infection, most of our patients were anti-HCV positive (78.5%) of whom 76% had chronic HCV infection. All of them have eventually been treated and finally achieved SVR at least 12 months before HCC diagnosis. However, most of them were cirrhotics (79%) at that time. It is well known that cirrhosis is the main risk factor for HCC in CHC and all patients with cirrhosis should be closely monitored and followed even after successful antiviral therapy.
Data concerning possible factors associated with the survival rate among patients with TDT who develop HCC remain unclear. It is well established that the development of HCC is the main factor affecting the survival of patients with chronic liver disease.[27,28] The prognostic factors for survival in patients with HCC are related to tumor status (number and size of nodules, presence of vascular invasion, extrahepatic spread), liver function and general tumor-related health status. Previous population-based data from Italy suggested that in patients with TDT and HCC, the average survival was 3.5 months in 2004 and rose to 11.5 months in 2014.[3,24] In our cohort, the analysis, after adjusting for age, has indicated that advanced BCLC stages were associated with poor survival. To our knowledge, this is the first real-life study evaluating prognostic factors affecting the survival of TDT patients with HCC.
The decision of the HCC treatment method was mainly based on the BCLC algorithm. However, we have to keep in mind that TDT has been considered as a relative contraindication for liver transplantation and this therapeutic approach was not available in our patients with early stage HCC. Moreover, major operations like surgical HCC resections are limited due to the problematic peri-operative management of these patients. Only two of our patients underwent resection of the tumor as initial treatment but both were relapsed within the next six months and were subsequently treated with loco-regional therapies. According to BCLC, systemic algorithm therapy is indicated in the advanced stage of the disease. In general, these patients bear a poor prognosis, with expected median survival times of 6–8 months. A large double-blinded placebo-controlled phase III study showed that the median overall survival of patients in the sorafenib group was 10.7 months compared to 7.9 months in the placebo group (HR, 0.69; 95% CI 0.55–0.87; p = 0.00058), representing a 31% decrease in the relative risk of death. In our study, these patients achieved a median survival period of 5 months (3-12). Patients with early stage HCC treated with RFA have an overall median survival of about 36 months which may extend to >5 years after successful treatment. Patients with intermediate stage HCC by BCLC treated with TACE have an overall survival of about 16 months which may extend to >40 months in well selected patients.[32,33] Our patients who have been treated with TACE/RFA achieved an overall survival of 12 months (2-96) which is much lower than expected. A possible explanation is that mortality in these patients may be influenced by several other complications and also that the biological activity of HCC in these patients is more aggressive, as can be hypothesized by the very high αFP levels.
The absence of a comparable group of patients with TDT without HCC, which would further provide robustness on the estimation of surveillance of HCC, is the main limitation of our study. We did demonstrate, however, the characteristics and risk factors of HCC and the main prognostic factors of survival in this specific group of patients.
- Moukhadder HM, Halawi R, Cappellini MD, Taher AT.
Hepatocellular carcinoma as an emerging morbidity in the thalassemia
syndromes: a comprehensive review. Cancer 2017;123:751-758. https://doi.org/10.1002/cncr.30462 PMid:27911488
- Loukopoulos D. Haemoglobinopathies in Greece: prevention programme over the past 35 years. Indian J Med Res 2011;134:572-6
C, Garani MC, Forni GL, Cappellini MD, Cassinerio E, Fidone C, Spadola
V, Maggio A, Restivo Pantalone G, Piga A, Longo F, Gamberini MR, Ricchi
P, Costantini S, D'Ascola D, Cianciulli P, Lai ME, Carta MP, Ciancio A,
Cavalli P, Putti MC, Barella S, Amendola G, Campisi S, Capra M, Caruso
V, Colletta G, Volpato S. Hepatocellular carcinoma in thalassaemia: an
update of the Italian Registry. Br J Haematol. 2014;167:121-126. https://doi.org/10.1111/bjh.13009 PMid:24992281
- Nikolopoulou G, Zisouli A. Viral hepatitis. Available from: http://www.keelpno.gr/en-us/home.aspx
KP, Foudoulaki LE, Papoulia EI, Sofroniadou KE. Seroprevalence of
hepatitis B surface antigen (HBsAg) among first-time and sporadic blood
donors in Greece: 1991-1996. Transfusion Medicine. 2000;10:175-180. https://doi.org/10.1046/j.1365-3148.2000.00257.x PMid:10972911
HZ, Liu YP, Guleng B, Ren JL. Hepatitis B Virus-Related Hepatocellular
Carcinoma: Pathogenic Mechanisms and Novel Therapeutic Interventions.
Gastrointest Tumors 2014;1:135-45. https://doi.org/10.1159/000365307 PMid:26676160 PMCid:PMC4645579
D, Zanella A, Farma E, De Mattei C, Bosoni P, Zappa M, Picone A, Mozzi
F, Rebulla P, Cappellini MD, Allain JP, Sirchia G. A multicenter
prospective study on the risk of acquiring liver disease in
anti-hepatitis C virus negative patients affected from homozygous
b-thalassemia. Blood. 1998;92:3460-3464. https://doi.org/10.1182/blood.V92.9.3460 PMid:9787188
A, Rigano P, Renda D, Di Salvo V, Pignatti CB, Guddo F, Buccellato A,
Nicoli N, Maggio A. Hepatocellular carcinoma on cirrhosis-free liver in
a HCV-infected thalassemic. Am J Hematol 2005;78:158-159. https://doi.org/10.1002/ajh.20289 PMid:15682406
E, Prati D, Suter F, Maggiolo F, Caprioli F, Sonzogni A, Fraquelli M,
Paggi S, Conte D. Age at infection affects the longterm outcome of
transfusion-associated chronic hepatitis C. Blood 2002;99:4588-4591. https://doi.org/10.1182/blood-2001-12-0192 PMid:12036892
G, Dalekos G, Sypsa V, Yurdaydin C, Buti M, Goulis J, Calleja JL, Chi
H, Manolakopoulos S, Mangia G, Gatselis N, Keskin O, Savvidou S, de la
Revilla J, Hansen BE, Vlachogiannakos I, Galanis K, Idilman R, Colombo
M, Esteban R, Janssen HL, Lampertico P.PAGE-B predicts the risk of
developing hepatocellular carcinoma in Caucasians with chronic
hepatitis B on 5-year antiviral therapy. J Hepatol 2016;64:800-806. https://doi.org/10.1016/j.jhep.2015.11.035 PMid:26678008
RL, Baack B, Smith BD, Yartel A, Pitasi M, Falck-Ytter Y. Eradication
of hepatitis C virus infection and the development of hepatocellular
carcinoma: a meta-analysis of observational studies. Ann Intern Med
2013;158:329-337. https://doi.org/10.7326/0003-4819-158-5-201303050-00005 PMid:23460056
- Mancuso A. Hepatocellular carcinoma in thalassemia: A critical review. World J Hepatol 2010;2:171-174. https://doi.org/10.4254/wjh.v2.i5.171 PMid:21160991 PMCid:PMC2999281
SA, Stratakou S, Koulentaki M, Voumvouraki A, Mantaka A, Samonakis D,
Notas G, Kouroumalis EA. Long-term change in incidence and risk factors
of cirrhosis and hepatocellular carcinoma in Crete, Greece: a 25-year
study. Ann Gastroenterol 2017;30:357-363. https://doi.org/10.20524/aog.2017.0135 PMid:28469367 PMCid:PMC5411387
- Kew MC. Hepatic iron overload and hepatocellular carcinoma. Liver Cancer 2014;3:31-40. https://doi.org/10.1159/000343856 PMid:24804175 PMCid:PMC3995380
- Kew MC. Hepatic iron overload and hepatocellular carcinoma. Cancer Lett 2009;286:38-43. https://doi.org/10.1016/j.canlet.2008.11.001 PMid:19081672
- Gandon Y, Olivié D, Guyader D. Non-invasive assessment of hepatic iron stores by MRI. Lancet 2004;363:357-362. https://doi.org/10.1016/S0140-6736(04)15436-6
JS, McCarville MB, Loeffler RB, Smeltzer MP, Onciu M, Hoffer FA, Li CS,
Wang WC, Ware RE, Hillenbrand CM. R2* magnetic resonance imaging of the
liver in patients with iron overload. Blood 2009;113:4853-4855. https://doi.org/10.1182/blood-2008-12-191643 PMid:19264677 PMCid:PMC2686136
P, Turati F, Carioli G, Rodriguez T, La Vecchia C, Malvezzi M, Negri E.
Global trends and predictions in hepatocellular carcinoma mortality. J
Hepatol 2017;67:302-309. https://doi.org/10.1016/j.jhep.2017.03.011 PMid:28336466
M, Kolly P, Knoepfli M, Herrmann E, Zweifel M, von TenggKobligk H,
Candinas D, Dufour JF. Treatment allocation in hepatocellular
carcinoma: Assessment of the BCLC algorithm. Ann Hepatol 2016;15:82-90 https://doi.org/10.5604/16652681.1184233 PMid:26626644
Pantalone G, Renda D, Valenza F, D'Amato F, Vitrano A, Cassarà F,
Rigano P, Di Salvo V, Giangreco A, Bevacqua E, Maggio A.Hepatocellular
carcinoma in patients with thalassaemia syndromes: clinical
characteristics and outcome in a long term single centre experience. Br
J Haematol. 2010;150:245-247. https://doi.org/10.1111/j.1365-2141.2010.08180.x PMid:20433678
J, Victor D, Asham EH, Burroughs SG, Boktour M,Saharia A, Li X,
Ghobrial RM, Monsour HP Jr. Hepatocellular carcinoma: a review. J
Hepatocell Carcinoma 2016;3:41-53. https://doi.org/10.2147/JHC.S61146 PMid:27785449 PMCid:PMC5063561
S, Ito K, Watanabe H, Nakano T, Moriya K, Shintani Y, Fujie H, Tsutsumi
T, Miyoshi H, Fujinaga H, Shinzawa S, Koike K, Horie T. Mitochondrial
iron accumulation exacerbates hepatic toxicity caused by hepatitis C
virus core protein. Toxicol Appl Pharmacol. 2015;282:237-243. https://doi.org/10.1016/j.taap.2014.12.004 PMid:25545986
- Kew MC, Asare GA. Dietary iron overload in the African and hepatocellular carcinoma. Liver Int 2007;27:735-741. https://doi.org/10.1111/j.1478-3231.2007.01515.x PMid:17617115
C, Rugolotto S, De Stefano P, Zhao H, Cappellini MD, Del Vecchio GC,
Romeo MA, Forni GL, Gamberini MR, Ghilardi R, Piga A, Cnaan A. Survival
and complications in patients with thalassemia major treated with
transfusion and deferoxamine. Haematologica 2004;89:1187-1193.
M, Tanaka H, Shiraishi Y, Unida T, Imamura M, Fujimoto A, Fujita M,
Sasaki-Oku A, Maejima K, Nakano K, Kawakami Y, Arihiro K, Aikata H,
Ueno M, Hayami S, Ariizumi SI, Yamamoto M, Gotoh K, Ohdan H, Yamaue H,
Miyano S, Chayama K, Nakagawa H. Characterization of HBV integration
patterns and timing in liver cancer and HBV-infected livers. Oncotarget
2018;9:25075-25088. https://doi.org/10.18632/oncotarget.25308 PMid:29861854 PMCid:PMC5982772
- EASL Recommendations on Treatment of Hepatitis C 2018. J Hepatol 2018;69:461-511. https://doi.org/10.1016/j.jhep.2018.03.026 PMid:29650333
Clinical Practice Guidelines: Management of hepatocellular carcinoma.
European Association for the Study of the Liver. J Hepatol
- Cabibbo G, Enea M,
Attanasio M, Bruix J, Craxi A, Camma C. A metaanalysis of survival
rates of untreated patients in randomized clinical trials of
hepatocellular carcinoma. Hepatology 2010;51:1274-1283. https://doi.org/10.1002/hep.23485 PMid:20112254
C, Stavroulakis E, Karmaniolou I. A narrative review of perioperative
management of patients with thalassaemia. Anaesthesia 2014;69:494-510. https://doi.org/10.1111/anae.12591 PMid:24601913
A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and
treatment: the BCLC update and future prospects. Semin Liver Dis
2010;30:61-74. https://doi.org/10.1055/s-0030-1247133 PMid:20175034
JM, Ricci S, Mazzaferro V, Hilgard P, Gane E, Blanc J-F, de Oliveira
AC, Santoro A, Raoul JL, Forner A, Schwartz M, Porta C, Zeuzem S,
Bolondi L, Greten TF, Galle PR, Seitz JF, Borbath I, Häussinger D,
Giannaris T, Shan M, Moscovici M, Voliotis D, Bruix J; SHARP
Investigators Study Group. Sorafenib in advanced hepatocellular
carcinoma. N Engl J Med 2008;359:378-390. https://doi.org/10.1056/NEJMoa0708857 PMid:18650514
JM, Bruix J. Systematic review of randomized trials for unresectable
hepatocellular carcinoma: Chemoembolization improves survival.
Hepatology 2003;37:429-442. https://doi.org/10.1053/jhep.2003.50047 PMid:12540794
- Burrel M, Reig M, Forner A,Barrufet M, de Lope CR, Tremosini S, Ayuso C, Llovet JM, Real MI, Bruix J . Survival of patients with hepatocellular carcinoma treated by transarterialchemoembolisation (TACE) using Drug Eluting Beads. Implications for clinical practice and trial design. J Hepatol 2012;56:1330-1335. https://doi.org/10.1016/j.jhep.2012.01.008 PMid:22314428