Undefined/non-malignant hepatic nodules are associated with early occurrence of HCC in DAA-treated patients with HCV-related cirrhosis

Angelo Sangiovanni, Eleonora Alimenti, Riccardo Gattai, Roberto Filomia, Elisabetta Parente, Luca Valenti, Luca Marzi, Gaia Pellegatta, Guglielmo Borgia, Martina Gambato, Natalia Terreni, Ilaria Serio, Luca Belli, Filippo Oliveri, Sergio Maimone, Matteo Brunacci, Roberta D'Ambrosio, Laura Virginia Forzenigo, Francesco Paolo Russo, Mariagrazia RumiMichele Barone, Anna Ludovica Fracanzani, Giovanni Raimondo, Edoardo Giovanni Giannini, Maurizia Rossana Brunetto, Erica Villa, Elia Biganzoli, Massimo Colombo, Pietro Lampertico

Research output: Contribution to journalArticlepeer-review


Background & Aim: An unexpected early increase in incidence, recurrence and clinical aggressiveness of hepatocellular carcinoma (HCC) has been reported (and refuted) in patients with HCV-related cirrhosis following direct-acting antiviral (DAA) treatment. To address this controversy, we performed a prospective multicenter study on consecutively enrolled cirrhotic patients, with or without a history of HCC, undergoing DAA therapy. Patients and methods: A total of 1,161 HCC-free cirrhotics (group 1) and 124 cirrhotics who had received a curative treatment for an HCC (group 2) were enrolled. Clinical features, including presence of undefined/non-malignant liver nodules (UNMNs), were analyzed with respect to HCC incidence and recurrence. Results: During a median study time of 17 months in group 1 and 16 months in group 2, de novo HCC developed in 48 patients (yearly incidence 3.1/100 patient-years, 75% BCLC 0-A) and recurred in 40 (mean yearly incidence 29.9/100 patient-years, 83% BCLC 0-A). A peak of HCC instant incidence was observed at 4.2 months in group 1 patients with UNMNs, and at 7.7 months in group 2. By multivariable Cox regression models, UNMNs (hazard ratio [HR] 3.11; 95% CI 1.47–6.57: p = 0.003), ascites detected any time before enrolment (HR 3.04; 95% CI 1.23–7.51; p = 0.02), and alpha-fetoprotein log-value (HR 1.90; 95% CI 1.05–3.44; p = 0.03) were the variables independently associated with the incidence of de novo HCC, while history of alcohol abuse (HR 2.10; 95% CI 1.08–4.09; p = 0.03) and history of recurrence of HCC (HR 2.87; 95% CI 1.35–6.09; p = 0.006) were associated with HCC recurrence. Conclusion: An early high incidence of both de novo HCC, in patients with UNMNs, and recurrent HCC was observed in DAA-treated patients; this was not accompanied by increased tumor aggressiveness. Lay summary: This prospective study focuses on the risk of developing de novo or recurrent hepatocellular carcinoma (HCC) after direct-acting antiviral (DAA) treatment in patients with hepatitis C-related cirrhosis. We found that DAA treatment was associated with an early high HCC incidence in patients with undefined or non-malignant nodules, as well as in those with a history of complete response to HCC treatment. Whether this is related to the presence of clinically undetectable nests of cancer cells or to precancerous lesions that may progress to overt HCC upon DAA treatment remains unanswered. No evidence of increased clinical aggressiveness was reported in de novo or recurrent HCC.

Original languageEnglish
Pages (from-to)593-602
JournalJournal of Hepatology
Issue number3
Publication statusPublished - 2020


  • Cirrhosis
  • Direct-acting antivirals
  • Hepatocellular carcinoma
  • Non-malignant liver nodules
  • Undefined liver nodules

ASJC Scopus subject areas

  • Hepatology


Dive into the research topics of 'Undefined/non-malignant hepatic nodules are associated with early occurrence of HCC in DAA-treated patients with HCV-related cirrhosis'. Together they form a unique fingerprint.

Cite this