AGA Clinical Practice Update on Screening and Surveillance for Hepatocellular Carcinoma in Patients With Nonalcoholic Fatty Liver Disease: Expert Review

Abstract

Nonalcoholic fatty liver disease (NAFLD) is a leading etiology for chronic liver disease with an immense public health impact and affects >25% of the US and global population. Up to 1 in 4 NAFLD patients may have nonalcoholic steatohepatitis (NASH). NASH is associated with significant morbidity and mortality due to complications of liver cirrhosis, hepatic decompensation, and hepatocellular carcinoma (HCC). Recent data confirm that HCC represents the fifth most common cancer and is the second leading cause of cancer-related death worldwide, and NAFLD has been identified as a rapidly emerging risk factor for this malignancy. NAFLD-associated liver complications are projected to become the leading indication for liver transplantation in the next decade. Despite evidence that NAFLD-associated HCC may arise in the absence of cirrhosis, is often diagnosed at advanced stages, and is associated with lower receipt of curative therapy and with poorer survival, current society guidelines provide limited guidance/recommendations addressing HCC surveillance in patients with NAFLD outside the context of established cirrhosis. Limited data are presently available to guide clinicians with respect to which patients with NAFLD should undergo HCC surveillance, optimal screening tools, frequency of monitoring, and the influence of coexisting host-and disease-related risk factors. Herein we present an evidence-based review addressing HCC risk in patients with NAFLD and provide Best Practice Advice statements to address key issues in clinical management.

Hepatocellular Carcinoma and Non-Alcoholic Fatty Liver Disease: A Step Forward for Better Evaluation Using Ultrasound Elastography

“…Moreover, several studies illustrated the high risk of HCC in cirrhotic NAFLD patients; in this particular case, bi-annual ultrasound (US) surveillance is universally recommended [ 14 , 23 ]. However, there are no clear guidelines for cost-effective surveillance of non-cirrhotic NAFLD patients [ 24 ].…”

Clinical Characteristics of a Non-Alcoholic Fatty Liver Disease Population Across the Fibrosis Spectrum Measured by Magnetic Resonance Elastography: Analysis of Screening Data

“…Magnetic resonance (MR) elastography (MRE) can non-invasively determine liver stiffness, a surrogate marker for assessing liver fibrosis, via analysis of shear waves induced in the liver by low-frequency vibrations applied to the abdominal wall [6,7]. Indeed, MRE has been shown to predict fibrosis in patients with NAFLD, with high diagnostic accuracy [3,6,7]. In a pooled analysis of individual participant-level data (n = 232), MRE was able to discriminate any fibrosis (stage 1, area under the receiver-operating curve [AUC] 0.86), significant fibrosis (stage 2, AUC 0.87), advanced fibrosis (stage 3, AUC 0.90), and cirrhosis (stage 4, AUC 0.91) [8].…”

Should you advocate for hepatocellular carcinoma surveillance in patients with alcohol-related liver disease or non-alcoholic fatty liver disease?

“…A recently updated American Gastroenterology Association clinical practice guideline recommends that HCC screening should be considered in all NAFLD patients with cirrhosis as well as advanced liver fibrosis, where non-invasive approaches combining serological tests with elastography examinations in staging liver fibrosis in NAFLD are preferred. 9 On the other hand, a European multicenter study showed that 1-and 2-year cumulative incidence of HCC development in patients with alcoholic cirrhosis were up to 1.8% and 5.2%, respectively, which were high enough to justify surveillance for the disease in these patients. 10 On the contrary, a need for regular surveillance remains questionable in non-cirrhotic patients with NASH or ALD.…”