更新!看更新版《中国肝细胞癌经动脉化疗栓塞治疗临床实践指南》谈接受介入治疗的HCC患者抗HBV治疗

2021-10-23 医学论坛网 医学论坛网

近日,中国医师协会介入医师分会组织全国肝癌介入及相关领域多学科专家,在2018版指南的基础上修订并更新形成《中国肝细胞癌经动脉化疗栓塞(TACE)治疗临床实践指南(2021年版)》。

近日,中国医师协会介入医师分会组织全国肝癌介入及相关领域多学科专家,在2018版指南的基础上修订并更新形成《中国肝细胞癌经动脉化疗栓塞(TACE)治疗临床实践指南(2021年版)》(以下简称2021年版指南)[1]。2021年版指南分为概述、TACE适应证和禁忌证、围手术期处理、手术操作、术中和术后不良反应、并发症及其处理等多个部分。

 

值得一提的是,在TACE围手术期处理部分,2021年版指南对于术前HBV筛查提出了明确要求,并且关于抗HBV治疗的推荐意见较2018年版指南更加积极、明确和具体

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01

重点解读2021年版指南抗HBV治疗部分

 

2021年版指南明确TACE术前进行HBV筛查

 

2021年版指南建议术前进行HBV标志物的检查,包括乙肝两对半[乙肝表面抗原(HBsAg)、乙肝表面抗体(HBsAb/抗HBs)、e抗原(HBeAg)、e抗体(HBeAb/抗‑HBe)、核心抗体(HBcAb/抗‑HBc)],HBV脱氧核糖核酸(HBV DNA)定量,评价患者慢性肝炎状态和病毒复制活跃程度。

 

2021年版指南对抗病毒治疗的启动时间、
药物选择、疗程和治疗目标都提出了明确的推荐意见

 

启动时间:HBsAg阳性的肝癌患者,无论HBV DNA定量检测数值是否有增加,在肝癌治疗前需要积极进行抗病毒治疗,以减少TACE治疗后HBV再激活和相关肝炎的发生概率,及提高TACE治疗后的存活率(证据质量Ⅰ,推荐强度A)。

 

药物选择:推荐使用核苷(酸)类似物长期服用,如丙酚替诺福韦(TAF)、替诺福韦酯(TDF)或恩替卡韦(ETV)等(证据质量Ⅰa,推荐强度A)。同时指出需注意抗病毒药物本身的副反应,如肾脏功能损害、骨质疏松的发生和管理优先选择强效、耐药率低、安全性好的能够让患者长期服用的药物。

 

疗程和治疗目标:原则上抗病毒治疗纳入介入治疗的全程管理中,尽量使HBV DNA滴度控制到最低水平(临床不可检出)(证据质量Ⅰa,推荐强度A)。

 

02

TAF强效、低耐药、骨肾安全性好,是介入治疗HCC患者的优选抗HBV药物

 

TAF是一种新型核苷酸类逆转录酶抑制剂,于2018年在我国上市,是近十年来为数不多的获批上市的创新抗HBV治疗药物之一。

 

此前,在19个国家或地区191家中心开展了2项(108/110研究)3期研究,随机、双盲、活性药物对照临床试验[2,3],以评估TAF、TDF两种药物治疗慢性HBV感染患者的有效性和安全性,其中108研究纳入425例HBeAg阴性患者,110研究纳入873例HBeAg阳性患者。双盲期,共有866例患者接受TAF治疗,382例患者接受TDF治疗。


结果显示:

1)TAF可快速降低HBV病毒载量,4周即可降低HBV DNA近3log10IU/mL[2,3](图1),治疗96周完全病毒学应答(HBV DNA<29 IU/mL)在HBeAg阳性与阴性患者中分别达73%和90%[2-4](图2)。

 

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图1 TAF治疗组4周即可降低HBV -DNA近3log10IU/mL

 

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图2 TAF治疗组96周病毒学完全应答率在HBeAg阳性与阴性患者中分别达73%和90%

 

2)TAF治疗240周(5年)耐药率(基因型耐药)为0[2,5,6](图3)。

 

图片

图3 TAF治疗240周(5年)耐药率(基因型耐药)为0

 

3)TAF的骨肾安全性显著优于TDF:TAF治疗96周,患者的髋关节和脊柱骨密度保持稳定,骨安全性显著优于TDF4(图4);此外,TAF组肾小球滤过率(eGFRCG)下降幅度和β2微球蛋白/肌酐比值(β2M:Cr)值均较小(图5),提示96周期间TAF肾脏安全性显著优于TDF4

 

图片

图4 96周期间TAF骨安全性更好

 

 

图片

图5 96周期间TAF肾脏安全性好

 

108/110研究结果表明,TAF可快速强效抑制HBV复制,5年“0”耐药,骨肾安全性好,是介入治疗HBV-HCC患者的优选抗HBV药物。

 

综上所述,2021年版指南建议介入治疗的HCC患者需全程联合抗病毒治疗,而TAF因其高病毒抑制率、低耐药性和良好的骨肾安全性,有利于患者的长期治疗,是优选抗HBV药物。

 

参考文献:

1. 中国医师协会介入医师分会临床诊疗指南专委会,中国肝细胞癌经动脉化疗栓塞(TACE)治疗临床实践指南(2021年版)

2. Buti M, et al. Lancet Gastroenterol Hepatol. 2016 Nov; 1(3): 196-206

3. Chan HL, et al. Lancet Gastroenterol Hepatol. 2016 Nov; 1(3): 185-195

4. Agarwal K, et al. J Hepatol. 2018 Apr;68(4):672-681.

5. Chan HLY, et al. AASLD 2020. 803

6.Henry Lik Yuen Chan, et al. 2018 AASLD. Poster: 386

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  3. [GetPortalCommentsPageByObjectIdResponse(id=1979216, encodeId=217019e9216bc, content=<a href='/topic/show?id=3b90e79787f' target=_blank style='color:#2F92EE;'>#细胞癌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=77978, encryptionId=3b90e79787f, topicName=细胞癌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e457184, createdName=qingting, createdTime=Tue Jun 21 02:58:13 CST 2022, time=2022-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1984604, encodeId=66981984604bd, content=<a href='/topic/show?id=40d93356656' target=_blank style='color:#2F92EE;'>#化疗栓塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33566, encryptionId=40d93356656, topicName=化疗栓塞)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/4v5DMqK7WnzoBdibNsryQ8OEM5gFSdRH9j3HNCKPfKXlObInweOSHdQPATeTicYp7nvg3bsgicjLgRkdlhrpry21w/132, createdBy=6bf82500013, createdName=ms5822920152752585, createdTime=Fri Aug 19 11:58:13 CST 2022, time=2022-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836707, encodeId=93d91836e071e, content=<a href='/topic/show?id=f9d08524be' target=_blank style='color:#2F92EE;'>#HBV#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8524, encryptionId=f9d08524be, topicName=HBV)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e87531, createdName=klivis, createdTime=Tue Sep 13 01:58:13 CST 2022, time=2022-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1863613, encodeId=b8d2186361311, content=<a href='/topic/show?id=c0b68135561' target=_blank style='color:#2F92EE;'>#肝细胞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81355, encryptionId=c0b68135561, topicName=肝细胞)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d59291, createdName=xjy02, createdTime=Tue Apr 19 14:58:13 CST 2022, time=2022-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2031840, encodeId=f1542031840e7, content=<a href='/topic/show?id=5df2460e269' target=_blank style='color:#2F92EE;'>#实践指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46072, encryptionId=5df2460e269, topicName=实践指南)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=796422, createdName=lvliquan, createdTime=Sat Feb 12 03:58:13 CST 2022, time=2022-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1259545, encodeId=965712595454d, content=<a href='/topic/show?id=2200854517' target=_blank style='color:#2F92EE;'>#HCC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8545, encryptionId=2200854517, topicName=HCC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1324476, encodeId=495513244e651, content=<a href='/topic/show?id=42b922e7350' target=_blank style='color:#2F92EE;'>#临床实践#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22773, encryptionId=42b922e7350, topicName=临床实践)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35fc2500023, createdName=yanjie6253_56072842, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1572698, encodeId=593315e2698d0, content=<a href='/topic/show?id=413922e74cd' target=_blank style='color:#2F92EE;'>#临床实践指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22774, encryptionId=413922e74cd, topicName=临床实践指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=276d15780972, createdName=lily1621, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1063310, encodeId=aeff10633101b, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Sat Oct 23 23:50:05 CST 2021, time=2021-10-23, status=1, ipAttribution=)]
    2022-09-13 klivis
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    2022-04-19 xjy02
  5. [GetPortalCommentsPageByObjectIdResponse(id=1979216, encodeId=217019e9216bc, content=<a href='/topic/show?id=3b90e79787f' target=_blank style='color:#2F92EE;'>#细胞癌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=77978, encryptionId=3b90e79787f, topicName=细胞癌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e457184, createdName=qingting, createdTime=Tue Jun 21 02:58:13 CST 2022, time=2022-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1984604, encodeId=66981984604bd, content=<a href='/topic/show?id=40d93356656' target=_blank style='color:#2F92EE;'>#化疗栓塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33566, encryptionId=40d93356656, topicName=化疗栓塞)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/4v5DMqK7WnzoBdibNsryQ8OEM5gFSdRH9j3HNCKPfKXlObInweOSHdQPATeTicYp7nvg3bsgicjLgRkdlhrpry21w/132, createdBy=6bf82500013, createdName=ms5822920152752585, createdTime=Fri Aug 19 11:58:13 CST 2022, time=2022-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836707, encodeId=93d91836e071e, content=<a href='/topic/show?id=f9d08524be' target=_blank style='color:#2F92EE;'>#HBV#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8524, encryptionId=f9d08524be, topicName=HBV)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e87531, createdName=klivis, createdTime=Tue Sep 13 01:58:13 CST 2022, time=2022-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1863613, encodeId=b8d2186361311, content=<a href='/topic/show?id=c0b68135561' target=_blank style='color:#2F92EE;'>#肝细胞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81355, encryptionId=c0b68135561, topicName=肝细胞)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d59291, createdName=xjy02, createdTime=Tue Apr 19 14:58:13 CST 2022, time=2022-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2031840, encodeId=f1542031840e7, content=<a href='/topic/show?id=5df2460e269' target=_blank style='color:#2F92EE;'>#实践指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46072, encryptionId=5df2460e269, topicName=实践指南)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=796422, createdName=lvliquan, createdTime=Sat Feb 12 03:58:13 CST 2022, time=2022-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1259545, encodeId=965712595454d, content=<a href='/topic/show?id=2200854517' target=_blank style='color:#2F92EE;'>#HCC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8545, encryptionId=2200854517, topicName=HCC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1324476, encodeId=495513244e651, content=<a href='/topic/show?id=42b922e7350' target=_blank style='color:#2F92EE;'>#临床实践#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22773, encryptionId=42b922e7350, topicName=临床实践)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35fc2500023, createdName=yanjie6253_56072842, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1572698, encodeId=593315e2698d0, content=<a href='/topic/show?id=413922e74cd' target=_blank style='color:#2F92EE;'>#临床实践指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22774, encryptionId=413922e74cd, topicName=临床实践指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=276d15780972, createdName=lily1621, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1063310, encodeId=aeff10633101b, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Sat Oct 23 23:50:05 CST 2021, time=2021-10-23, status=1, ipAttribution=)]
  6. [GetPortalCommentsPageByObjectIdResponse(id=1979216, encodeId=217019e9216bc, content=<a href='/topic/show?id=3b90e79787f' target=_blank style='color:#2F92EE;'>#细胞癌#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=48, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=77978, encryptionId=3b90e79787f, topicName=细胞癌)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e457184, createdName=qingting, createdTime=Tue Jun 21 02:58:13 CST 2022, time=2022-06-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1984604, encodeId=66981984604bd, content=<a href='/topic/show?id=40d93356656' target=_blank style='color:#2F92EE;'>#化疗栓塞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33566, encryptionId=40d93356656, topicName=化疗栓塞)], attachment=null, authenticateStatus=null, createdAvatar=https://thirdwx.qlogo.cn/mmopen/vi_32/4v5DMqK7WnzoBdibNsryQ8OEM5gFSdRH9j3HNCKPfKXlObInweOSHdQPATeTicYp7nvg3bsgicjLgRkdlhrpry21w/132, createdBy=6bf82500013, createdName=ms5822920152752585, createdTime=Fri Aug 19 11:58:13 CST 2022, time=2022-08-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1836707, encodeId=93d91836e071e, content=<a href='/topic/show?id=f9d08524be' target=_blank style='color:#2F92EE;'>#HBV#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=50, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8524, encryptionId=f9d08524be, topicName=HBV)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e87531, createdName=klivis, createdTime=Tue Sep 13 01:58:13 CST 2022, time=2022-09-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1863613, encodeId=b8d2186361311, content=<a href='/topic/show?id=c0b68135561' target=_blank style='color:#2F92EE;'>#肝细胞#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=46, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81355, encryptionId=c0b68135561, topicName=肝细胞)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=d59291, createdName=xjy02, createdTime=Tue Apr 19 14:58:13 CST 2022, time=2022-04-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2031840, encodeId=f1542031840e7, content=<a href='/topic/show?id=5df2460e269' target=_blank style='color:#2F92EE;'>#实践指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=42, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46072, encryptionId=5df2460e269, topicName=实践指南)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=796422, createdName=lvliquan, createdTime=Sat Feb 12 03:58:13 CST 2022, time=2022-02-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1259545, encodeId=965712595454d, content=<a href='/topic/show?id=2200854517' target=_blank style='color:#2F92EE;'>#HCC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=26, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8545, encryptionId=2200854517, topicName=HCC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=55683, createdName=仁医06, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1324476, encodeId=495513244e651, content=<a href='/topic/show?id=42b922e7350' target=_blank style='color:#2F92EE;'>#临床实践#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=31, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22773, encryptionId=42b922e7350, topicName=临床实践)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=35fc2500023, createdName=yanjie6253_56072842, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1572698, encodeId=593315e2698d0, content=<a href='/topic/show?id=413922e74cd' target=_blank style='color:#2F92EE;'>#临床实践指南#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=22774, encryptionId=413922e74cd, topicName=临床实践指南)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=276d15780972, createdName=lily1621, createdTime=Mon Oct 25 13:58:13 CST 2021, time=2021-10-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1063310, encodeId=aeff10633101b, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Sat Oct 23 23:50:05 CST 2021, time=2021-10-23, status=1, ipAttribution=)]
    2021-10-25 仁医06
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    2021-10-23 1209e435m98(暂无昵称)

    学习了,谢谢分享

    0

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