I read with interest the article by Hsu et al. regarding the use of peg-interferon (Peg-IFN) plus ribavirin (RBV) to reduce postoperative recurrence of hepatocellular carcinoma (HCC) in patients with hepatitis C virus (HCV) infection. I would like to congratulate Dr. Hsu and his colleagues for their remarkable work to enroll 2,237 antiviral-naïve HCV-infected patients with curatively resected HCC to determine the benefits of “adjuvant therapy” with Peg-IFN plus RBV to reduce the recurrence of HCC. However, some points need clarification.
The investigators adopted a case-control study matched for age, gender, and cirrhosis to compare Peg-IFN plus RBV-treated and RBV-untreated HCV-related HCC patients. Among 2,237 HCV patients with surgically resected HCC, only 239 (11%) patients received antiviral therapy. It is customary for clinicians to preclude patients with decompensated cirrhosis to receive antiviral regimen with IFN. Our previous study revealed that an appreciably high incidence of HCC may develop in HCV patients with successful management of variceal bleeding. As shown in the results, apart from antiviral therapy, age, cirrhosis, diabetes mellitus (DM), and minor surgical resection were factors predictive of HCC recurrence. It appeared that more patients in the untreated patients group were older, with DM, and received minor resection. The severity of cirrhosis, such as Child- Pugh's class, history of ascites, variceal bleeding, bacterial infections, and complications of patients receiving Peg-IFN >16 weeks and <16 weeks, and frequency of sustained virological response (SVR) were not mentioned in this article. Thus, before we could draw a final conclusion, a well-matched comparison is required. A previous study demonstrated that an SVR to IFN/RBV reduced the incidence of HCC. Based on the current study, we could presume that only a small proportion of HCV-related, surgically resected HCC patients could be benefited from the institution of Peg-IFN plus RBV in terms of the reduction of HCC recurrence.
Gin-Ho Lo, M.D.
Department of Medical Research Digestive Center E-DA Hospital, Kaohsiung I-Shou University Kaohsiung, Taiwan