The hurdle with remaining risk for hepatocellular carcinoma in cirrhotic patients after a hepatitis C cure.

After introduction of new direct acting antivirals (DAAs) against hepatitis C, the cure rate has increased substantially especially in patients with liver cirrhosis. Decreased but remaining risk for hepatocellular carcinoma (HCC) has been shown in patients with liver cirrhosis after cure, in previous studies with interferon (IFN)-based treatments. This risk for HCCs is expected to become the next hurdle in the management of hepatitis C patients, as the number of treated and cured patients with liver cirrhosis is increasing dramatically. At the recent International Liver Congress 2016, Barcelona, Spain, a potentially alarming report was presented by Buonfiglioli F et al., among otherwise positive reports, for patients with prior HCC being treated with DAAs. This preliminary report showed a high early recurrence rate of 29 % for HCC after initiation of DAA treatment in patients with treated HCC, at follow-ups 12-24 weeks post-treatment. Another study was published just prior to this report by Reig M et al. showing similarly high recurrence rate for HCC. In this study, patients who have been treated for HCC with ablation, resection or transarterial chemoembolization, and no sign of remaining HCC at treatment start, were analysed for the risk of HCC recurrence after DAA treatment initiation. After a median follow-up time of 5.7 months, recurrence rate of HCC was seen in 28 %. The disadvantage of these studies was the lack of any control group, but these figures were unexpectedly high compared to figures in previous studies. These findings need to be further explored and eventually confirmed in other studies before making any firm conclusions and change of the routine practice. Until we have more data, the eventual risks for early HCC recurrence and other risks must be weighed against other benefits of these DAAs, halting liver disease progression, on an individual basis.