Chapter 9: The co-infected CÔte d’Ivorian

A 37-year-old man from Cote d’Ivoire presented with abdominal pain and swelling and mild dyspnoea. He was known to have HIV since 2003 and was on anti-retroviral therapy (truvada, darunavir, ritonavir) with a CD4 count of 457/mm³

• 1. Who should be screened for liver cancer and what screening should be undertaken?

  Show Answer

  Correct answer:
  Patients with chronic hepatitis B or with hepatitis C should have screening consisting of liver ultrasound and serum a-fetoprotein (AFP) measurement every 6 months. This has been shown not to prevent liver cancer but to detect tumours at an earlier stage when they are curable by surgery.

• 2. What does the liver ultrasound show?

  Show Answer

  Correct answer:
  

• 3. What does the CT scan show?

  Show Answer

  Correct answer:
  

Ultrasound showed cirrhosis with a highly vascular mass in the left lobe of the liver. CT scan showed a large heterogeneous ill-defined area of low attenuation within the left lobe of the liver measuring 6 cm in diameter. As the tumour was greater than 5cm in diameter it was not suitable for surgical resection. The current criteria for curative surgical resection are: single tumour <5 cm diameter or up to three tumours all <3 cm diameter.

• 4. What infections are implicated in the pathogenesis of hepatic and biliary tumours?

  Show Answer

  Correct answer:
  

  • Hepatitis B: there are two billion people worldwide with HBV of whom 10% are chronically infected. Men with chronic HBV have a 40% lifetime risk of hepatocellular cancer.
  • Hepatitis C: there are 170 million people with HCV which is always chromic unless successfully treated with recently available curative drugs (at vast expense).
  • Clonorchis sinensis: the Chinese liver fluke affects 200 million people and is the most common trematode in Asia. It is associated with cholangiocarcinoma.
  • Opisthorchis viverrini: the South East Asian liver fluke is endemic in Thailand, Laos, Cambodia and Vietnam. It is associated with cholangiocarcinoma
  • Opisthorchis felineus: the cat liver fluke affects 1.5 million people in Russia and is also associated with cholangiocarcinoma. All three flukes are caught from eating raw fish.

As he has advanced hepatocellular cancer he is offered palliative treatment with sorafenib, a receptor tyrosine kinase inhibitor that is associated with a modest but significant increase in time to disease progression. Fortunately his oncologist consults his HIV physician first as there are significant drug interactions between the sorafenib and the antiretrovirals. The ritonavir will reduce the metabolism of the sorafenib potentially leading to toxic levels. Conversely, the sorafenib could lead to raised and potentially toxic levels of raltegravir, one of the likely alternative antiretrovirals. Knowledge of pharmacokinetics is essential when prescribing systemic anticancer therapy.

Sorafenib could raise raltegravir levels as it is metabolized by UGT1A1.