Hepatocellular Carcinoma Arising after Hepatitis B Seroconversion Without Cirrhosis, when and How Surveillance is Done?

Approximately 18 million people chronically infected with Hepatitis B Virus (HBV) in Indonesia. HBV is a major contributor for the development of hepatocellular carcinoma (HCC). The therapy endpoint for chronic HBV is HBsAg seroclearance or seroconversion. However, in small percentage, HCC can still develop even after seroconversion. This is the first case of such occurrence reported in Indonesia. We report a case of 57-years old male diagnosed with chronic HBV infection 9 years ago by serologic marker and quantitative HBV DNA. The patient was given Entecavir therapy for 6 years and resulted in HBV DNA clearance and HBeAg seroconversion, however HBsAg persisted at lower levels. The treatment then switched to PegIFN α-2a 180 mg for 1 year, in which resulted in HBsAg seroclearance with normal abdominal ultrasound and hepatic elastography showed no sign of cirrhosis. Three months later, he developed anti-HBsAg and subsequently the patient was loss to follow up. After 2 years the patient showed up with right upper quadrant pain. Abdominal ultrasound and CT scan was performed in which suggestive of HCC confirmed by liver biopsy. Two months after admission the patient experienced esophageal varices ruptured and treated with ligation. With this development of HCC after seroconversion, it is crucial for physicians to establish the surveillance criteria for resolved Hepatitis B patients.