I've seen several patients that have their liver fibrosis reduced (determined by elastography) after treating hepatitis C with DAA and achieving 12 months of post-treatment undetectable viral load.
This is most obvious in patients that have a baseline result of F3 or F4. They frequently have their fibrosis reduced to values below 8-9 kPa, which would fall in the F1 or F2 category if they still had hepatitis C.
We've been screening these patients for HCC, and probably will do so for some more years (at least until we have more experience with the DAA), but does someone have a different perspective?
Thanks.
Very little fibrosis, so very low cirrhosis risk for years. Also now no viral load, so such a small HCC risk that screening now not necessary. This is the result of the successful treatments.
I suggest to continue doing periodical revisions with US every 6 months
Dr James, Dr Rodrigo,
Thank you for your insight. Two answers with two opposite opinions. I think it reflects our present limited knowledge.
HCC risk is very low in HCV non-cirrhotic patients so that screening could be considered not necessary in this group. However, there are some data reporting a higher incidence of HCC in DAA treated patients, probably due to the close follow-up of these patients. And given the fact that they succeeded in eradicating the virus, it would be a pity to lose them from follow-up and risk having them later with advanced HCC. I agree with Prof Rodrigo that continuing screening at 6 months would be reasonable.
Regarding fibrosis reversal in DAA treated patients, what elastography method did you use? It would be great to have some multicentric data put together and see what we get from it.
Dr Balaban,
Thank you for your input.
Like you mentioned, it has been described that some patients develop HCC soon after completion of the treatment. We've had at least one case of a patient in which that happened.
But we're starting to question if it makes sense to have them on routine screening ad eternum, if they are doing well for several years.
The basic question here is to determine if a patient with a pre-treatment significant fibrosis remains at risk for HCC after treatment is completed and fibrosis has reversed. And if so, for how long does he remain at risk.
As for the elastography, our patients are being evaluated at another hospital with FibroScan.
Best regards.
I perfectly agree, the issue of HCC risk in patients with pre-treatment significant fibrosis in whom reversal of fibrosis is noted after DAA remains to be studied. We are at the beginning of DAA treatment and long term follow-up of these patients is needed to draw recommendations.
I fully agree with Dr. Balaban opinion and we must follow these patients because after DAA treating the incidence of HCC is increased after the eradication of the HCV
Best regards
I guess it will take several more years of data from ongoing studies around the world to have a definitive answer on this-
https://www.eurekalert.org/pub_releases/2017-04/eaft-idt041117.php
It is convenient to follow every 6 months with US of the liver and Fibroscan together determinations
I agree entirely with Drs Balaban and Rodrigo. At least for now we need to monitor these patients. Transient elastography (Fibroscan) measures liver stiffness. This is contributed to by fibrosis and liver inflammation. Treatment with DAAs results in a rapid reduction in liver inflammation and an equally rapid decline in Fibroscan score. Reversal of fibrosis is much slower and we don't yet know to what extent DAA therapy has on HCC risk in patients who were cirrhotic prior to therapy.
It is important to note that many of the HCC which appears to develop a short while after HCV eradication by DAAs was already present in microscopic state/small size while the treatment was ongoing and remained undetected on routine screening. Therefore it is always recommended to measure baseline serum alpha fetoprotein or desgamma carboxy prothrombin along with a dynamic multiphasic contrast-enhanced study on a multidetector row CT (MDCT) of liver which detects even very small cancers. The follow up also should ideally be 6 monthly repeating of the above tests especially if chances of cancer are high as in the mentioned case who has F3/F4 fibrosis but it depends on cost also. MRI or contrast enhanced USG of liver can also help.