Changing Patterns of Hepatocellular Carcinoma after Treatment with Direct Antiviral Agents

Abstract

<b><i>Introduction:</i></b> The impact of direct antiviral agents (DAAs) on the development of hepatocellular carcinoma (HCC) is controversial. One important aspect of this controversy is the changing pattern of HCC. <b><i>Objective:</i></b> In this study, we attempted to assess the changes in the pattern of HCC after treatment with DAAs. <b><i>Methods:</i></b> A total of 51 HCC patients after DAA treatment and 54 HCC patients without DAA treatment were included. The diagnosis of HCC was based on typical dynamic CT and/or MRI criteria in both groups. Liver status was assessed by means of the fibrosis 4 index (Fib-4), Child-Pugh classification, and model for end-stage liver disease (MELD). HCC infiltrative pattern, portal vein thrombosis (PVT), local and distant metastases, and α-fetoprotein (AFP) level were compared in the 2 groups. The staging of HCC and treatment decisions were made in both groups following the Milan criteria, Barcelona Clinic Liver Cancer staging, tumor-node-metastasis staging, and Cancer of the Liver Italian Program categorization. <b><i>Results:</i></b> The mean age of the HCC patients after DAA treatment (59.1± 7.4 years) was older than that of the HCC patients without DAA treatment. There was no significant difference between groups regarding sex distribution. The mean Fib-4 score (4.84 ± 3.53) was significantly lower in HCC patients after DAA treatment than in those without DAA treatment. The frequency of the infiltrative HCC pattern, PVT, and regional lymph node metastasis was significantly higher in HCC patients after DAA treatment than in those without DAA treatment (<i>p</i> ≤ 0.05); mean AFP level (5,085.2 ± 11,883.2 ng/mL) was also significantly higher. HCC patients after DAA treatment had significantly advanced stages and limited treatment options (<i>p</i> ≤ 0.05). <b><i>Conclusion:</i></b> The changing HCC pattern after DAA treatment may suggest the need for new HCC staging and treatment protocols.

Patterns of Hepatocellular Carcinoma After Direct Antiviral Agents and Pegylated-Interferon Therapy

“…On the other hand, patients who had PI for their treatment presented after a mean of seven years as shown in Table 2 . HCC was detected in a cohort for up to four years after starting DAA treatment [ 4 ]. Another study reported that cases do not show a downtrend of HCC for the first 3.6 years.…”

“…HCC patients after DAA treatment were found to have a significantly higher malignant portal vein invasion and local spread through malignant lymphadenopathy [9]. Another prospective study showed similar findings of significant multifocal and infiltrative HCC patterns after DAA treatment [4]. Romano et al suggested that tumor growth in patients with aggressive tumors after HCV therapy is faster and with a higher number of nodules and extra-hepatic metastases [10].…”

“…It is more concerning because the achievement of SVR should be associated with a decreased risk of cancer. Some studies have mentioned that HCC-induced DAA can be very infiltrative and shows aggressive behavior [4] even at the initial presentation so here we explore if there is any difference between the initial presentation of patients with HCC presenting after DAA or interferon. We aim to look at the involvement in detail of portal vein thrombosis (PVT), lesion type, staging, and timing of initial presentation between patients treated with DAA and interferon.…”

Current situation of viral hepatitis in Egypt

“…Moreover, no vascular invasion, lymph node metastasis, or distant metastasis was reported. Two Egyptian studies compared the HCC pattern in HCV patients without and with DAA treatment 239,240 (Table 1). Both the studies reported a higher frequency of compensated liver disease, elevated alpha‐fetoprotein, vascular invasion, and lymph node metastasis among HCC patients after DAA treatment.…”

No evidence of a more aggressive pattern of hepatocellular carcinoma after direct acting antivirals –results from a single center observational study

“…Recent studies which evaluated the behavior of HCC after DAAs, have found more aggressive features of HCC. For instance, a recent article by Fayoume et al found that multiplicity and infiltrative patterns were more common in DAAs-treated HCC patients compared to naïve HCC patients (13). Another study revealed that malignant PVT and lymphadenopathy were significantly more frequent in DAAstreated HCC patients (14).…”