2021 Update: Expert consensus on antiviral therapy for HBV/HCV-related hepatocellular carcinoma

Introduction With the advancement of anti-hepatitis B virus (HBV) and hepatitis C virus (HCV) therapeutics, the Hepatocarcinology Group of the Chinese Medical Association Hepatology Branch organizes experts in related fields to "HBV/HCV-related hepatocellular carcinoma antiviral therapy experts The Consensus has been updated
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Based on previous expert recommendations/consensus, this version of the consensus analyzes the results of new evidence in recent years and forms relevant recommendations.
Relevant staff from primary medical institutions provide guidance and reference
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HBV/HCV-related hepatocellular carcinoma antiviral therapy expert consensus recommendation 1: Chronic HBV/HCV infection is an important cause of hepatocellular carcinoma (HCC).
Antiviral therapy is used to replicate HBV in patients with chronic hepatitis B (CHB) Suppress to the lowest level or achieve functional cure, and eliminate HCV in patients with chronic hepatitis C (CHC) to achieve cure, which can significantly reduce the occurrence of HCC.
It is the most effective means for secondary prevention of HBV/HCV-related HCC (1A) ; Antiviral therapy is one of the effective basic treatment measures after the occurrence of HBV/HCV-related HCC, which can reduce the damage of hepatitis virus to the liver, reduce or even reverse liver fibrosis or cirrhosis, delay tumor progression, reduce HCC recurrence, and protect the liver It is one of the important means of tertiary prevention to ensure the effects of other comprehensive treatments and improve overall survival rate (1B)
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HBV-related HCC recommendation 2: Active and effective antiviral treatment for CHB patients is an important secondary prevention measure to prevent the occurrence of HBV-related HCC (1A)
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For the antiviral treatment of CHB patients, it is recommended to choose first-line nucleoside (acid) analogs (NUCs) or peginterferon (PEG-IFN) treatment (1A), and adjust the treatment plan in time according to the patient's response to the drug
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Recommendation 3: For CHB patients undergoing antiviral therapy, alternative indicators for assessing the effect of HBV-related HCC secondary prevention are: HBV DNA is less than the lower limit of the high-sensitivity detection method, HBsAg negative and alanine aminotransferase (ALT) are long-term Below the upper limit of normal (ULN) (2B)
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 Recommendation 4: For CHB patients with high risk of HCC, antiviral therapy should be based on first-line NUCs, and PEG-IFN combined with NUCs can be considered for treatment without PEG-IFN contraindications (2A)
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For patients who are being treated with NUCs, if they fail to meet the relevant indicators (with HBV-related cirrhosis patients within 24 weeks or non-cirrhotic CHB patients within 48 weeks to achieve the recommendation 3), consider switching to or combining other first-line anti-HBV drugs , Follow up closely, and further adjust and optimize the treatment plan if necessary; for CHB patients with functional cure prospects, you can choose to combine PEG-IFN therapy (2A) to enhance the antiviral effect and minimize the occurrence of HBV-related HCC
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 Recommendation 5: For the antiviral treatment of CHB patients, the main goal is to use current drugs and treatment options to achieve HBsAg clearance, that is, functional cure, and further reduce the incidence of HCC (1A)
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For patients with liver cirrhosis who have achieved HBsAg disappearance through antiviral therapy (clinical cure), regular follow-up monitoring of the occurrence of HCC is still required (1B)
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Recommendation 6: As long as HBV-related HCC patients are positive for HBsAg, regardless of whether HBV DNA is detectable, they should be given first-line NUCs antiviral therapy immediately (1A)
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Patients without contraindications to PEG-IFN can be treated with PEG-IFN combined with NUCs (2A) after surgery.
Combined treatment can improve overall survival (OS)
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 Recommendation 7: For patients with Child-Pugh Class A liver function and mild liver cirrhosis, antiviral therapy should be actively treated at the same time as TACE treatment (1A)
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For patients with Child-Pugh Class B liver function and severe liver cirrhosis, TACE treatment should be given to improve liver function and antiviral therapy for 1-2 weeks according to the patient's liver function status and tumor burden (2A)
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For HBV-related HCC patients undergoing surgery, radiotherapy, systemic chemotherapy, and targeted therapy, follow this recommendation
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 Recommendation 8: Patients with HBsAg-negative but anti-HBc-positive HCC at baseline before TACE treatment are not recommended for preventive antiviral therapy (2A)
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If HBV reactivation occurs, antiviral therapy should be given immediately
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For HBsAg-negative but anti-HBc-positive patients who are at high risk of HBV reactivation and receive higher-intensity TACE, close follow-up monitoring must be performed to detect HBV reactivation as soon as possible and receive antiviral therapy (1A)
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 Recommendation 9: For patients with HBV-related HCC undergoing liver transplantation, it is recommended to start antiviral therapy with first-line NUCs as early as possible before liver transplantation (1A)
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HCV-related HCC recommendation 10: It is recommended to use direct antiviral drugs (DAAs) as the first-line drugs for the treatment of HCV infection, and it is no longer recommended to use interferon (IFN)-containing treatment options (1A)
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Recommendation 11: Obtaining sustained virological response (SVR) after DAAs treatment can significantly reduce the risk of HCV-related HCC
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Patients with chronic HCV infection with previous liver cirrhosis or a history of HCC should be monitored for HCC regardless of whether they have obtained SVR.
It is recommended that liver ultrasound combined with serum baseline high alpha-fetoprotein (AFP) examination, at least every 3-6 months1 Times (1A)
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Recommendation 12: All HCV infected persons who are to be treated with DAAs should be screened for HBV infection before treatment, and should be screened for human immunodeficiency virus (HIV) based on the medical history (1A)
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 Recommendation 13: For patients with HCV-HIV or HCV-HBV co-infection, the DAAs treatment plan is the same as that of HCV single infection and has the same effect.
For specific drugs, see Appendix 1
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For patients who also meet the standards of HBV antiviral treatment, corresponding HBV antiviral treatment can be given.
Entecavir (ETV), tenofovir disoproxil fumarate (TDF), propofol tenofovir (TAF) or AIDS can be selected.
First-line therapy such as mitenofovir (TMF) (1A)
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Recommendation 14: If HBsAg is positive but HBV DNA cannot be detected, it is recommended that preventive treatment of HBV should be carried out before the start of DAAs treatment, at least until 3 months after the end of DAAs treatment
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For HCV-infected individuals who are single anti-HBc positive but HBV DNA negative, amino ALT, HBsAg and HBV DNA levels should be monitored, and anti-HBV treatment should be initiated in time if necessary (1B)
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Recommendation 15: DAAs for HCV-related HCC patients undergoing radical treatment such as surgical resection and local ablation can reduce the risk of tumor recurrence, reduce the risk of death, and improve overall survival
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There is no tumor recurrence 4-6 months after radical treatment of HCV-related HCC, and DAAs treatment can be started (2B)
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 Recommendation 16: For compensated patients with acceptable liver function (MELD score <20) after radical treatment of HCC, DAAs treatment is feasible, and pan-genotypic or gene-specific regimens can be selected; such as liver decompensation (MELD) Score ≥20 points) or a history of liver decompensation before treatment, it is recommended to give a treatment plan without protease inhibitors, pan-genotypic DAAs (such as sofosbuvir combined with vepatavir, etc.
) (2B)
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Please refer to Appendix 1-3 for specific medication and usage
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Recommendation 17: For HCC patients with acceptable liver function (MELD score <20) and waiting for a long time for transplantation, DAAs may be considered before transplantation
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For HCC patients with poor liver function (MELD score ≥ 20 points) and short waiting time for transplantation, DAAs treatment can be postponed until transplantation
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The choice of treatment plan needs to be considered comprehensively according to factors such as transplantation time, liver function, HCV genotype, donor and recipient HCV infection, and combined medication (2B)
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Recommendation 18: For HCV-related HCC patients receiving TACE treatment, DAAs antiviral therapy can reduce the risk of death and increase OS; reduce the risk of HCC recurrence in patients who have achieved complete remission (2B)
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Reference: Hepatocarcinology, Chinese Medical Association Hepatology Branch.
Expert consensus on antiviral therapy for HBV/HCV-related hepatocellular carcinoma (updated in 2021) [J].
Journal of Clinical Hepatobiliary Diseases, 2021,37(10): 2292-2302.
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