the main cause of death in patients with chronic hepatitis c is hepatocellular carcinoma ( hcc ) [ 1 , 2 , 3 , 4 ] . moreover , hcc complicated with hepatitis c virus ( hcv)-related chronic hepatitis or cirrhosis recurs frequently after curative therapies for the initial hcc . nevertheless , recent studies on the efficacy of interferon ( ifn ) in the prevention of recurrence of hcc and survival after curative resection of the hcc in patients with hcv cirrhosis have provided conflicting data [ 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 ] . moreover , the japanese guidelines ( the study group for the standardization of treatment of viral hepatitis including cirrhosis , ministry of health , labour and welfare of japan ) stated that long - term ifn therapy should be considered for patients with compensated cirrhosis in order to prevent hcc in 2008 . recently reported that long - term ifn monotherapy using a low dose of natural ifn - alpha was effective for preventing hepatocarcinogenesis in elderly patients with chronic hepatitis c . no case report has so far documented the prevention of future hcc recurrence by the long - term use of low - dose pegylated ifn ( peg - ifn ) . this report presents a case of hcv associated with cirrhosis with a sustained prevention of hcc recurrence by long - term administration of super - low - dose peg - ifn - alpha 2b . a 78-year - old male was diagnosed to have hcv infection and hcc in the right lobe of the liver in 1997 . he had a sufficient hepatic reserve and underwent partial hepatectomy for the first hcc . his liver function was monitored and periodically checked for recurrent hcc by blood tests and computed tomography . a solitary tumor was detected in s7 of the liver , which was treated by percutaneous microwave coagulation therapy . subsequent treatment of recurrence in both lobes with transarterial lipiodol chemoembolization ( tace ) was performed on six occasions ( 2003 , 2006 , 2007 , 2008 , 2008 and 2009 ) and by the combination treatment of tace and radiofrequency ablation in 2005 , with clinical , analytical and imaging follow - up studies . the right hepatic artery became completely obstructed . moreover , a narrow neovascularity from the gastroduodenal artery formed a collateral artery . intravascular chemoembolization would have been difficult to perform after the last tace in february 2009 . the japanese guidelines recommend that long - term ifn therapy should be considered for preventing hcc in patients with hcv - related cirrhosis . adverse events have a tendency to occur in elderly patients [ 18 , 19 ] . his serum hcv rna level was 2.8 log iu / ml and serotype of hcv was 2 . therefore , he was treated with peg - ifn , because standard ifn might have a more negative effect on his quality of life than peg - ifn . moreover , a previous paper reported that patients with low hcv rna levels tend to eradicate hcv rna with a low dose of ifn . therefore , super - low - dose peg - ifn therapy ( peg - ifn - alpha 2b , 20 g / week ) was started in february 2009 after providing the patient with detailed information regarding his condition and treatment , and after gaining his informed consent . peg - ifn ( a total of 1,240 g ) was administered over an extended period . serum alt showed a tendency to decrease after peg - ifn therapy was started , and it has remained within the normal range since march 2009 . no side effects such as flu - like symptoms occurred during the peg - ifn treatment period . the most common side effect of peg - ifn therapy is bone marrow suppression with leukopenia , thrombocytopenia and anemia . he did not have to withdraw the treatment due to this peg - ifn side effect throughout this treatment . he has been free from hcc recurrence for more than 20 months , even though ifn treatment was discontinued . many patients with chronic hepatitis c infection are generally elderly . in addition , the age of hcv - related hcc patients has been increasing , with a peak around age 70 [ 22 , 23 ] . nevertheless , a study concluded that elderly patients with genotype 2a and 2b should receive ifn therapy . moreover , a recent meta - analysis showed that ifn treatment after curative resection or ablation of hcc in hcv - related cirrhotic patients prevents hcc recurrence and improves survival . ifn therapy reduces the incidence of hepatocarcinogenesis in patients with hcv infection who achieve sustained virological response . the inhibitory effect of ifn on development of hcc in patients with chronic hepatitis c aged 60 and over is limited to patients achieving sustained virological response following 6 months of ifn monotherapy . sustained prevention of hcc recurrence was accomplished when the current patient achieving sustained virological response . peg - ifns have long elimination half - lives and steady serum concentrations that may prevent viral rebound between doses and reduce the risk of the super - low - dose peg - ifn therapy which was administered to the current case may have contributed to the favorable outcome . a nonrandomized retrospective study observed the beneficial effect of long - term natural ifn - alpha therapy on hepatocarcinogenesis in elderly chronic hepatitis c patients . this paper showed that the alpha - fetoprotein ( afp ) baseline was decreased after initiation of ifn therapy in most patients . moreover , the cumulative rate of hcc development in patients whose serum level of afp was within normal limits after initiation of ifn therapy was lower than that of patients with a high level of afp despite ifn therapy . this paper concluded that afp was a suitable indicator in long - term ifn therapy for protecting against hcc . in this case , the serum level of afp had remained within the normal limits before the last tace performance . nevertheless , the tumor marker pivka ii showed a tendency to decrease after peg - ifn therapy was started in the current patient , and it has remained within normal limits . this is very important for the sustained prevention of hcc recurrence with peg - ifn therapy as well . the serum level of pivka ii showed a slow decline to the normal range over 5 months . a previous paper demonstrated that ifn - alpha potentiated the apoptotic effect of trail in human hepatoma cells by regulating the expression of dr5 or survivin and by repressing trail - mediated nf-b activation . this low - dose peg - ifn therapy might induce the death and apoptosis of remaining hcc cells . fortunately , in patients with genotype 2 and low virus load , hcv rna tends to be eradicated with a small dose of ifn [ 29 , 30 , 31 , 32 ] . super - low - dose peg - ifn therapy was administered over a long period at the request of our patient . generally , peg - ifn is expensive and has a number of serious side effects . . a shorter period of peg - ifn therapy should be considered in future studies . in conclusion , this case report indicates that low - dose peg - ifn administration may successfully inhibit hepatitis c - related hcc recurrence of elderly patients .
a 78-year - old male who experienced multiple recurrences of hepatocellular carcinoma ( hcc ) with hepatitis c virus ( hcv)-related cirrhosis underwent transcatheter arterial chemoembolization and ablation and survived for more than 10 years . 
 his serum hcv rna level was 2.8 log iu / ml and the serotype of hcv was 2 . 
 he underwent long - term super - low - dose ( 20 g / week ) pegylated interferon - alpha 2b therapy to prevent recurrence of hcc . 
 he became negative for hcv rna 2 months later , and thereafter remained negative after the discontinuation of interferon therapy , and has not experienced a recurrence of hcc for more than 20 months .