CT Features of Hepatocellular Carcinoma in Hepatitis C Patients Who Received Direct Acting Antivirals

Background: Impact of direct-acting antivirals (DAAs) on hepatocellular carcinoma (HCC) development and progression, particularly post-treatment tumor behavior, remains a debated topic. Objectives: This study aimed to compare the CT imaging features of de novo HCC in HCV patients reaching a Sustained Virological Response (SVR) with DAAs versus DAA-naïve HCC patients. Patients and methods: A retrospective study included 90 chronic HCV patients who were divided into 2 groups: Group I (45 patients with de novo HCC following SVR from DAA therapy) and group II (45 treatment-naïve HCC patients). They underwent multiphasic CT scans (non-contrast, arterial, portal and delayed phases). Analyzed radiological features included tumor size, number, margin, enhancement patterns, washout timing, pseudocapsule, intratumoral heterogeneity, necrosis, dysmorphic vessels, aneurysms, arteriovenous shunts, malignant portal vein thrombosis (PVT), lymph node involvement, and distant metastasis. Tumor staging used the Barcelona Clinic Liver Cancer (BCLC) system. Results: Significant differences were observed, indicating more aggressive features in group (I). Post-DAA HCC (Group I) exhibited larger tumor size, multifocal/diffuse infiltration and atypical enhancement patterns. A significantly higher incidence of aggressive markers, including malignant PVT, regional lymph node involvement and distant metastasis were noted. Group (I) also showed more advanced BCLC staging and higher serum AFP levels. Linear regression identified DAA therapy as a significant predictor of aggressive HCC characteristics, despite comparable Child-Pugh class between groups. Conclusion: HCC arising after DAA-induced SVR demonstrated more aggressive radiological and clinical behavior than HCC in DAA-naïve patients, characterized by larger, infiltrative lesions, higher rates of metastasis and vascular invasion, and more advanced staging.