Hepatitis C Virus Infection, Antiviral Therapy, and Risk of Hepatocellular Carcinoma

Direct-acting antivirals sofosbuvir and daclatasvir attenuate carbon tetrachloride-induced liver fibrosis in mice

Background and aim

Advanced liver fibrosis is a major risk for developing hepatocellular carcinoma (HCC) in chronic hepatitis C virus (HCV) patients. Direct-acting antivirals (DAAs) which are used for treating HCV infection, produce more than 90% cure rate but do not seem to diminish the rate of occurrence or recurrence of HCC. This study aimed to investigate the effect of DAAs sofosbuvir (SOF) and daclatasvir (DAC) on carbon tetrachloride (CCl4)-induced fibrotic changes in mice.

Methods

Eighty adult male Swiss albino mice were randomly allocated into 8 groups (10 mice/group): normal control group, SOF group (receiving SOF 80 mg/kg body weight (BW), oral gavage, daily), DAC group (receiving DAC 30 mg/kg BW, oral gavage, daily), SOF + DAC group (receiving a combination of both, daily), CCl4 model group (receiving CCl4 2 mL/kg BW, intraperitoneal twice weekly) and three CCl4-intoxicated groups receiving either SOF or DAC or their combination. All CCl4 groups received CCl4 for 12 weeks followed by DAAs for another 12 weeks.

Results

CCl4-induced a significant elevation of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), and produced histopathological evidence of fibrosis and liver degeneration along with a significant increase (P ≤ 0.001) of the proliferation markers (proliferating cell nuclear antigen (PCNA) and Ki-67), hepatic stellate cells (HSCs) activation markers (alpha-smooth muscle actin (α-SMA) and glial fibrillary acidic protein (GFAP)), fibrosis marker (matrix metalloproteinase-9 (MMP-9)) and pro-inflammatory cytokine (tumor necrosis factor-alpha (TNF-α)). CCl4-intoxicated mice treated with SOF, DAC, or their combination revealed a significant amelioration (P ≤ 0.001) of CCl4-induced elevation of liver enzymes, fibrotic changes, and liver degeneration along with a significant attenuation (P ≤ 0.001) of CCl4-induced upregulation of all tested markers. The effects of SOF, DAC, and their combination on liver enzymes were comparable while the effect of SOF + DAC combination on mitigating CCl4-induced upregulation of the proliferation and HSCs activation markers was significantly stronger than either SOF or DAC alone. As for MMP-9 and TNF-α, the effects of DAC and SOF + DAC combination were comparable and both were more significant than that of SOF alone.

Conclusions

SOF and DAC may possess an antifibrotic effect that is independent of their role as antiviral agents against CCl4-induced liver injury. This might exclude the role of DAAs in early occurrence or accelerated recurrence of HCC through the progression of the HCV patients' pre-existing fibrosis. However, HCC patients treated with DAAs should be closely monitored with continuous HCC surveillance during and post-therapy.

Association of Nationwide Hepatitis B Vaccination and Antiviral Therapy Programs With End-Stage Liver Disease Burden in Taiwan

IMPORTANCE

Chronic infections of hepatitis B and C viruses are the main causes of end-stage liver disease (ESLD) worldwide. The successful control of viral hepatitis is critical to reducing the burden of ESLD.

OBJECTIVE

To examine the association of 2 world-first nationwide neonatal hepatitis B vaccinations and national antiviral therapy programs implemented in Taiwan (in 1984 and 2003, respectively) with the burden of ESLD.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included children and adults aged 5 to 39 years from the National Cancer Registry Database and the National Death Registry Database between 1979 and 2018 in Taiwan. Individuals who died from chronic liver disease (CLD) and cirrhosis and hepatocellular carcinoma (HCC) or were diagnosed with HCC were included for analysis. Analyses were performed in January 2021.

MAIN OUTCOMES AND MEASURES

The main outcomes were measures of age, period, and cohort associations with CLD mortality and HCC incidence and mortality using an age-period-cohort analysis.

RESULTS

Among the 43 604 individuals (mean [SD] age, 33.3 [6.0] years; 37 755 men [86.6%]) with ESLD in the cohort, there were 17 904 CLD deaths, 11 504 HCC deaths, and 14 196 HCC incident events. There was a significant increase in all 3 disease burdens after age 20 years. From 2004 to 2018, CLD mortality decreased by 26% (adjusted rate ratio [aRR], 0.74; 95% CI, 0.70-0.82), HCC mortality decreased by 50% (aRR, 0.50; 95% CI, 0.45-0.58), and HCC incidence decreased by 53% (aRR, 0.47; 95% CI, 0.44-0.52). A sharply declining association by cohort was observed from the 1982 to 1986 birth cohort to the 2007 to 2011 birth cohort, during which CLD mortality decreased by 82% (aRR, 0.18; 95% CI, 0.00-1.13), HCC mortality decreased by 63% (aRR, 0.37; 95% CI, 0.09-0.68), and HCC incidence decreased by 80% (aRR, 0.20; 95% CI, 0.00-0.48). The associations of age, period, and cohort were similar between male and female individuals and between urban and rural areas. The percentage of chronic hepatitis B infections in patients with HCC decreased from 83.3% (95% CI, 79.7%-86.5%) for those born from 1980 to 1984 to 55.6% (95% CI, 21.2%-86.3%) (from 2000 to 2004).

CONCLUSIONS AND RELEVANCE

These findings suggest that the national hepatitis B vaccination program and the antiviral therapy program jointly were associated with substantial reductions in the burden of ESLD in Taiwan.

The frequency, related cause of disease, and treatment of hepatitis B virus infection: A systematic review and meta-analysis in Iran

Background:

Hepatitis B virus (HBV) is one of the most dreadful viruses causing high mortality rates and serious damages to hepatocytes. The aim of this study was to assess the frequency, related causes/risk factors, and treatments of HBV infection in Iran by systematic review and meta-analysis.

Materials and Methods:

The data were obtained by a literature search in the PubMed, Scopus, SID, and Web of Sciences databases. Keywords included prevalence, risk factors, causes, treatment, and HBV. The Persian equivalents of these keywords were also searched. The time span included 2004 to2021. The Q and I² statistics were used to check heterogeneity among studies. The data were analyzed using Stata (version 14).

Results:

The frequencies of HBV infection and its pharmaceutical therapy were P = 6% (95% confidence interval [CI]: 4–9, I² = 95.2%, P < 0.001) and 19% (95% CI: 18%–30%, I² = 98.9%, P < 0.001), respectively. The most common risk factors/causes of HBV were narcotic consumption, blood-related factors, and transmission from infected individuals with the respective frequencies of 27% (95% CI: 16%–38%, I² = 88.7%, P < 0.001), 32% (95% CI: 11%–53%, I² = 99.8%, P < 0.001), 25% (95% CI: 10%–41%, I² = 99.3%, P < 0.001), and 15% (95% CI: 7%–22%, I² = 98.4%, P < 0.001), respectively.

Conclusion:

The most important causes of HBV infection were transmission from infected people, narcotic consumption, and blood-related factors. The main therapeutic intervention for HBV was pharmaceutical therapy.

Interleukin-17 haplotyping predicts hepatocellular carcinoma in sofosbuvir, pegylated interferon-alpha-2a & ribavirin treated chronic hepatitis C patients

Suspect has been directed towards some direct acting antivirals (DAAs) due to their reported association with hepatocellular carcinoma (HCC) development in chronic hepatitis C (CHC) patients. The mechanisms behind HCC development, following CHC treatment, were not well understood and may be linked to genetic variabilities in different patients which affect several cytokine productions involved in angiogenesis and inflammation. Of these variabilities, is the genetic polymorphisms in the interleukin-17 (IL-17) A receptor gene. Being an important pleiotropic cytokine, this study aimed to investigate the association between haplotypes in IL-17A receptor rs2275913 and rs3819024 and development of HCC in CHC patients treated with either triple therapy (sofosbuvir (SOF), pegylated interferon-alpha-2a (Peg-IFNα-2a) & ribavirin(RBV)) or with dual therapy (Peg-IFNα-2a&RBV). A cohort of 100 CHC patients was recruited in this study. Samples were tested for single nucleotide polymorphism (SNPs) in IL-17A receptor (rs2275913 and rs3819024) using TaqMan Genotyping assay. Our results showed that the presence of G-G haplotype in IL-17A (rs2275913& rs3819024) is inversely associated with HCC development in patients receiving triple therapy. While, high serum AFP levels are directly associated with HCC development in patients receiving triple therapy. However, in patients receiving dual therapy, HCC development was only associated with high serum alpha fetoprotein (AFP) levels and was not correlated to any specific allele in our studied SNPs. Such results highlight the importance of IL17A receptor gene haplotyping in the prediction of HCC development in patients receiving triple therapy. These results will aid in performing tailored, personalized strategy for CHC treatment.

Treatment of chronic hepatitis C regiments containing with recombinant interferon in patients with sustained virological response predicts risk of hepatocellular carcinoma: A meta-analysis

Given that evidence supporting chronic hepatitis C (CHC) infection developed chance for hepatocellular carcinoma (HCC) following antiviral agents therapy is controversial. We conducted a meta-analysis to examine the risk.We evaluated 20 retrospective and prospective cohort studies published up to 31 December 2017 which investigated the association between sustained virological response (SVR) and incidence of HCC patients treated with monotherapy interferon (IFN) or IFN plus ribavirin (RBV) therapy. The primary outcome of the study was the cumulative incidence of HCC. Odds ratio (OR) was used to evaluate the index of effect size for the association between SVR and treatment with IFN alone or IFN/RBV in CHC patients.SVR patients demonstrated a lower incidence of HCC compared to non-SVR patients. Non-SVR patients had greater odds of HCC incidence compared to SVR patients in the treatment of IFN plus RBV (pooled OR = 7.405, 95% CI = 4.689 to 11.694, P < .001). Non-SVR patients had greater odds of HCC incidence compared to SVR patients in the treatment of IFN monotherapy (pooled OR = 4.135, 95% CI = 3.009 to 5.682, P < .001). Lack of SVR to IFN therapy was significantly associated with greater risk of HCC incidence (pooled OR = 5.035, 95% CI = 3.915 to 6.474, P < .001).SVR could be as a predictor of HCC in CHC patients treated with IFN or IFN plus RBV, and have important implications during HCC screening, whereby patients who fail to achieve SVR need to be screened more rigorously.

A Downside to Hepatitis C Virus Cure? Vigilance Is Needed Regarding Hepatitis B Virus Reactivation, Organ Rejection, or Hepatocellular Carcinoma Progression

Cure of hepatitis C virus has become feasible in almost all patients. However, vigilance is needed in 3 scenarios: previous exposure to hepatitis B virus (HBV), history of organ transplantation, and history of cured hepatocellular carcinoma (HCC). The current data suggest that HBV reactivation occurs in about 10% of hepatitis B surface antigen (HBsAg)-positive patients and approximately 1% of hepatitis B core antibody-positive but HBsAg-negative patients. The risk of organ rejection is also around 1%, but can be fatal if not acted on immediately. Finally, the risk of early HCC recurrence may be increased but should not delay initiation of antiviral therapy in the setting of cured HCC; however, increased surveillance may be warranted.

Temporal trend and risk determinants of hepatocellular carcinoma in chronic hepatitis B patients on entecavir or tenofovir

This study aimed to elucidate the temporal change and determinants for the risk of HCC in patients with chronic hepatitis B continuously receiving NUC. Through analysis of the national healthcare database in Taiwan, we screened a total of 65 426 infected patients receiving entecavir or tenofovir for at least 3 months and excluded those with lamivudine, adefovir or telbivudine exposure, malignancy, end-stage renal failure or a diagnosis of HCC within 3 months of starting treatment. Eligible patients (N = 27 820) were followed until HCC occurrence, completion of the allowed 3-year regimen or 31 December 2013. During a median follow-up of 25.1 (12.1-35.6) months, 802 patients developed HCC, with 1-, 2- and 3-year cumulative incidence of 1.82% (95% CI, 1.66-1.99%), 3.05% (95% CI, 2.82-3.28%) and 4.06% (95% CI, 3.77-4.36%), respectively. HCC annual incidence decreased with an adjusted IRR of 0.73 (95% CI, 0.66-0.80) per yearly interval and was associated with cirrhosis (IRR, 10.07; 95% CI, 6.00-16.90 in age <40 years; 4.69; 95% CI, 3.94-5.59 in age ≧40 years), age (IRR, 3.38; 95% CI, 2.10-5.47 for 40-50 years; 6.92; 95% CI, 4.27-11.21 for 50-60 years; 12.50; 95% CI, 7.71-20.25 for ≧60 years; <40 years as reference), male sex (IRR, 1.71; 95% CI, 1.44-2.04), HCV coinfection (IRR, 1.27; 95% CI, 1.02-1.58) and diabetes (IRR, 1.24; 95% CI, 1.05-1.45). In conclusion, the risk of HCC in patients with chronic hepatitis B receiving entecavir or tenofovir declines over time and is determined by cirrhosis, age, male sex, HCV coinfection and diabetes.

Temporal improvement in survival of patients with hepatocellular carcinoma in a hepatitis B virus-endemic population

BACKGROUND AND AIM

Over the past decade, the management of hepatocellular carcinoma (HCC) and viral hepatitis has been improved. We explored survival trends and factors affecting survival of HCC in a hepatitis B virus (HBV)-endemic population.

METHODS

From 31 521 and 38 167 HCC registrants to the population-based national cancer registry in Korea, an HBV-endemic country, in the period of 2003-2005 and 2008-2010, we randomly sampled cohorts of 4515 and 4582 patients, respectively, for the investigation of clinical characteristics and survival.

RESULTS

Compared with Cohort 2003-2005, Cohort 2008-2010 had significantly better liver function (Child-Turcotte-Pugh class A, 64.2% vs 71.6%; P < 0.001) and had more advanced tumor stages (Barcelona Clinic Liver Cancer stage B-D, 45.8% vs 50.4%; P < 0.001). HBV was the predominant cause of HCC in both cohorts (62.5% vs 62.2%; P = 0.70). Cohort 2008-2010 had significantly better overall survival than Cohort 2003-2005 by age-adjusted univariate, multivariable, and propensity score-matched analyses (median survival time, 17.2 vs 28.4 months; P < 0.001). In a subcohort analysis, a consistently significant inter-cohort improvement in survival was observed only in patients with HBV-related HCC (median survival, 16.1 vs 30.4 months; P < 0.001). The annual number of patients with HCC receiving oral antiviral agents for HBV precipitously increased from 93 in 2005 to 28 520 in 2010 in the country.

CONCLUSIONS

The consistent improvement in survival of patients with HCC was confined to HBV-related HCC subcohort over the last decade in an HBV-endemic population. The survival improvement coincided with the exponential use of oral antiviral agents for HBV in the patients.

Prevalence of chronic viral hepatitis infections in Karaj, Iran

Introduction

Viral hepatitis is challenging for health and blood safety. Studies carried out on blood donors can help find the frequency and trending of hepatitis B and C infections in a community and also safety of donation. The study aim is to determine the prevalence of HBV and HCV in Karaj blood donors over a four year period between 2010 to 2013.

Methods

This study reports the results of a cross sectional seroepidemiological study of hepatitis B and C in blood donors. Data on hepatitis infection and demographic characteristics of donors were gathered from blood donor registries. Frequency of hepatitis infections were described with 95% confidence interval. Chi square and logistic regression were used for analysis.

Results

The frequency of HBV and HCV infection in Karaj blood donors was 0.40% and 0.18% respectively. In first time donors, HBV and HCV positivity risk was respectively 3.59 and 4.8 fold in people with primary education (OR=3.59; 95% CI between 2.68-4.80) comparing to academic level. Frequency of hepatitis B has decreased significantly (P<0.001) during study period but frequency of Hepatitis C has not changed significantly.

Conclusion

The frequencies of HBV and HCV infection in Karaj blood donor population is low. There are equal infection rates within both genders. This must be considered in controlling transmission of infection in this area.

Improved survival of patients with hepatocellular carcinoma and compensated hepatitis C virus-related cirrhosis who attained sustained virological response

BACKGROUND

Few studies examined the outcome of patients with hepatitis C virus (HCV)-related cirrhosis who developed hepatocellular carcinoma (HCC). The relative weight as determinant of death for cancer vs end-stage liver disease (ESLD) and the benefit of HCV eradication remain undefined. This multicentre, retrospective analysis evaluates overall survival (OS), rate of decompensation and tumour recurrence in compensated HCC patients treated with interferon (IFN) according to HCV status since HCC diagnosis.

METHODS

Two groups of patients with HCV-related cirrhosis and HCC were followed since HCC diagnosis: (i) compensated cirrhotics with prior sustained virological response (SVR) on IFN-based regimens (N=19); (ii) compensated cirrhotics without SVR (viraemic) (N=156).

RESULTS

Over a median follow-up of 3.0 years since the onset of HCC, OS was longer for HCC patients with SVR than for viraemic patients (log-rank P=.004). The 5-year OS rate was 65.9% in patients with SVR vs 31.9% in viraemic patients. Similar trends were reported for hepatic decompensation (log-rank P=.01) and tumour recurrence (log-rank P=.01). These findings were confirmed at multivariable and propensity score analysis. At propensity analysis, 0/19 compensated patients with SVR died for ESLD vs 7/19 (37%) viraemic patients (P=.004). HCC mortality was similar in the two groups.

CONCLUSIONS

Hepatocellular carcinoma patients with prior SVR and compensated cirrhosis at the time of tumour diagnosis have prolonged OS than viraemic patients. Given the lack of cirrhosis progression, no SVR patient ultimately died for ESLD while this condition appears the main cause of death among viraemic patients.

Recent Trends in the Epidemiology of Hepatocellular Carcinoma in Olmsted County, Minnesota: A US Population-based Study

BACKGROUND/AIM

The epidemiology of hepatocellular carcinoma (HCC) has changed in the United States recently. The aim of this study is to evaluate the recent trends of HCC epidemiology in Olmsted County, MN.

METHODS

Residents aged over 20 with newly diagnosed HCC were identified using the Rochester Epidemiology Project database. Clinical information was compared among patients diagnosed between 2000 and 2009 (era 1) and 2010 to 2014 (era 2).

RESULTS

Over 1.6 million person years of follow-up, 93 residents were diagnosed with HCC. The mean age was 67 and 71% were male. The age-adjusted and sex-adjusted incidence rates were 6.3 and 7.0 per 100,000 person years in the first and second eras (P=0.64). The proportion with hepatitis B virus etiology increased from 4% to 21% between the 2 eras (P<0.01), whereas there was a trend toward a decreasing proportion of hepatitis C virus etiology from 42% to 29% (P=0.20). Only 39% of HCC surveillance candidates had HCCs detected under surveillance and 41% of cirrhotic patients had unrecognized cirrhosis at the time of HCC diagnosis. Nonalcoholic fatty liver disease was associated with unrecognized cirrhosis and absence of cirrhosis at HCC diagnosis. More than half (56%) of patients presented at Barcelona Clinic Liver Cancer stage C or D and the median survival was 9.7 months. The overall survival had not changed over time.

CONCLUSIONS

The incidence of HCC remained stable after 2010 in Olmsted County. The proportion of hepatitis B virus-induced HCC increased, whereas there was a trend of decreasing proportion of hepatitis C virus-induced HCC. The overall survival in community residents with HCC remains poor.

Rapid Virological Response After Early Treatment with a Combined Therapy of Ledipasvir and Sofosbuvir in HCV Genotype 4 After Living Donor Liver Transplantation in a HCC Downstaged Patient: Case Report and Review of the Literature

Patient: Male, 54

Final Diagnosis: HCC with portal vein

Symptoms: Liver failure

Medication: —

Clinical Procedure: Hepatitis c treatment • hcc tratment

Specialty: Transplantology

Isolation as a strategy for controlling the transmission of hepatitis C virus (HCV) infection in haemodialysis units

BACKGROUND

The hepatitis C virus (HCV) infection affects about 2% of the world's population and can cause chronic liver infection and persistent long-term sequelae such as cirrhosis and liver cancer.The prevalence of HCV infection among people on haemodialysis is often higher than the general population. The virus is easily transmitted parenterally, and blood transfusions have previously played a significant role in transmission; however, erythropoietin therapy has reduced the need for transfusions, and coupled with improved screening of donated blood, has significantly decreased transmission by transfusion. Although control of hospital-acquired infection has improved with the advent of biosafety measures, stopping HCV transmission in haemodialysis units remains challenging.Isolating people infected with HCV involves physical separation from others to limit direct or indirect transmission and includes a number of strategies during dialysis. The evidence for isolating people infected with HCV during haemodialysis is sparse with some inconsistencies.

OBJECTIVES

To evaluate the benefits and harms of isolation of HCV-infected patients during haemodialysis on the transmission of HCV to other patients.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Specialised Register to 26 November 2015 through contact with the Information Specialist using search terms relevant to this review. We also searched the Latin American and Caribbean Health Sciences Literature Database (LILACS) (1982 to 2015), Web of Science Conference Proceedings Citation Index-Science (CPCI-S, 1990 to 2015), ProQuest Dissertations & Theses Database (1990 to 2015), and Open Grey (1990 to 2015).

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs and cluster RCTs evaluating the clinical benefits and harms of isolating HCV-infected patients during haemodialysis on the transmission of HCV to other patients. We considered incidence of dialysis-acquired HCV infection, all-cause mortality, and adverse effects associated with isolation as the primary outcomes.

DATA COLLECTION AND ANALYSIS

Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) or standardised mean difference (SMD) and 95% CI for continuous outcomes.

MAIN RESULTS

Only one study, which included 12 centres was identified: four centres used dedicated haemodialysis machines for HCV-infected patients and eight centres used non-dedicated machines. The total number of patients enrolled was 593. One centre was excluded after randomisation. Random sequence generation was not described and allocation concealment was not performed. Participants and personnel were not blinded and blinding of outcome assessors was not reported. Only 74.5% of the patients were followed for 9 months; and 47.3% were followed for an additional 9 months. The authors only reported one outcome, measuring the difference in the incidence of HCV in both groups. The authors did not consider the exposure time, to determine the adjusted rate of seroconversion risk/patient-year. The study reported that the incidence of HCV infection during the first follow-up period (9 months) was 1.6% in the dedicated group, and 4.7% in the non-dedicated one (446 patients analysed out of 593 randomised; RR 0.34, 95% CI 0.11 to 1.07). During the second follow-up period (18 months) the incidence was 1.3% in the dedicated group and 5.8% in the control (281 patients analysed out of 593 randomised; RR 0.22, 95% CI 0.05 to 1.02). Therefore, we found no differences in terms of the number of participants developing HCV infection when comparing the dedicated group with the usual care. Moreover, the evidence was of very low quality, which means that we have very little confidence in the effect estimate.

AUTHORS' CONCLUSIONS

The benefits and harms of isolation of HCV-infected patients during haemodialysis on the transmission of HCV to other patients are uncertain. Evidence from one short-duration cluster-randomised study with a high risk of bias did not find differences in terms of the number of participants developing HCV infection when comparing the use of dedicated haemodialysis machines for HCV infected patients with the use of non-dedicated machines.

Adjuvant sorafenib for hepatocellular carcinoma after resection or ablation (STORM): a phase 3, randomised, double-blind, placebo-controlled trial

BACKGROUND

There is no standard of care for adjuvant therapy for patients with hepatocellular carcinoma. This trial was designed to assess the efficacy and safety of sorafenib versus placebo as adjuvant therapy in patients with hepatocellular carcinoma after surgical resection or local ablation.

METHODS

We undertook this phase 3, double-blind, placebo-controlled study of patients with hepatocellular carcinoma with a complete radiological response after surgical resection (n=900) or local ablation (n=214) in 202 sites (hospitals and research centres) in 28 countries. Patients were randomly assigned (1:1) to receive 400 mg oral sorafenib or placebo twice a day, for a maximum of 4 years, according to a block randomisation scheme (block size of four) using an interactive voice-response system. Patients were stratified by curative treatment, geography, Child-Pugh status, and recurrence risk. The primary outcome was recurrence-free survival assessed after database cut-off on Nov 29, 2013. We analysed efficacy in the intention-to-treat population and safety in randomly assigned patients receiving at least one study dose. The final analysis is reported. This study is registered with ClinicalTrials.gov, number NCT00692770.

FINDINGS

We screened 1602 patients between Aug 15, 2008, and Nov 17, 2010, and randomly assigned 1114 patients. Of 556 patients in the sorafenib group, 553 (>99%) received the study treatment and 471 (85%) terminated treatment. Of 558 patients in the placebo group, 554 (99%) received the study treatment and 447 (80%) terminated treatment. Median duration of treatment and mean daily dose were 12·5 months (IQR 2·6-35·8) and 577 mg per day (SD 212·8) for sorafenib, compared with 22·2 months (8·1-38·8) and 778·0 mg per day (79·8) for placebo. Dose modification was reported for 497 (89%) of 559 patients in the sorafenib group and 206 (38%) of 548 patients in the placebo group. At final analysis, 464 recurrence-free survival events had occurred (270 in the placebo group and 194 in the sorafenib group). Median follow-up for recurrence-free survival was 8·5 months (IQR 2·9-19·5) in the sorafenib group and 8·4 months (2·9-19·8) in the placebo group. We noted no difference in median recurrence-free survival between the two groups (33·3 months in the sorafenib group vs 33·7 months in the placebo group; hazard ratio [HR] 0·940; 95% CI 0·780-1·134; one-sided p=0·26). The most common grade 3 or 4 adverse events were hand-foot skin reaction (154 [28%] of 559 patients in the sorafenib group vs four [<1%] of 548 patients in the placebo group) and diarrhoea (36 [6%] vs five [<1%] in the placebo group). Sorafenib-related serious adverse events included hand-foot skin reaction (ten [2%]), abnormal hepatic function (four [<1%]), and fatigue (three [<1%]). There were four (<1%) drug-related deaths in the sorafenib group and two (<1%) in the placebo group.

INTERPRETATION

Our data indicate that sorafenib is not an effective intervention in the adjuvant setting for hepatocellular carcinoma following resection or ablation.