Page 94 - Read Online

Bellentani. Hepatoma Res 2020;6:29 I http://dx.doi.org/10.20517/2394-5079.2020.10 Page 5 of 6

the NASH patient or patients with metabolic disease who should undergo screening and surveillance for
HCC, and many questions remain to be answered, including new and efficacious strategies for targeting
[25]
[24]
high-risk subjects in the general population . A recent evidence-based expert review tries to clarify
this matter, and summarizes the American Gastroenterology Association practical update on screening
[24]
and surveillance for HCC in patients with NAFLD/NASH . In this review, different practical guidelines
are suggested for 3 groups of patients: 1- patients with NASFLD/NASH and without advanced fibrosis;
[24]
2- patients with advanced fibrosis, and finally, 3- patients with NASH-cirrhosis . In the first group, based
on a recent national Veterans Affairs study in the USA, HCC incidence rates of patients with NASFLD/
NASH and not advanced fibrosis were 0.21/1000 person-years (0.02% annual risk) in NAFLD and
0.02/1000 person-years (0.002% annual) in controls [26,27] . Although there was a higher risk of developing
HCC in patients with earlier stages of NAFLD and low fibrosis than in those without NAFLD, the authors
concluded that the risk estimate is likely to be too low to justify routine screening in those who have early
[24]
NAFLD with no evidence of advanced fibrosis .
Considering the second group, HCC screening in patients who have NAFLD/NASH with advanced
fibrosis, as determined by combining at least 2 noninvasive score testing modalities suggestive of cirrhosis
(in the absence of biopsy-confirmed cirrhosis or overt cirrhosis on imaging), associated with diagnosis of
cirrhosis at elastography examination (i.e., with fibroscan or share-wave elastography, or quantitative MRI),
patients in whom both tests are concordant for advanced fibrosis or cirrhosis should be, on the contrary,
considered for HCC screening . Finally, in the third group, the incidence rate of HCC in NAFLD cirrhosis
[24]
is estimated to be > 1.5% per year, and therefore, screening for HCC in this group is justifiable, based on
cost-effectiveness considerations. Therefore, the best practice guidance recommendation is to consider
[24]
and offer HCC screening and surveillance to all patients with NAFLD/NASH compensated cirrhosis, in
patients with NAFLD/NASH and advanced fibrosis, but not in patients with simple NAFLD or NASH and
[24]
non-advanced fibrosis .

CONCLUSION
NAFLD/NASH is an important cause of liver disease worldwide and is associated with an increased risk
of developing HCC, either in the presence or absence of liver cirrhosis. The prevalence of metabolic liver
disease and of NASH-HCC is increasing in parallel with the prevalence of obesity and T2DM worldwide.
The future global burden of NAFLD-related HCC is going to become a major public health issue, so further
research to identify the factors involved in promoting inflammation and hepatocarcinogenesis in NAFLD/
NASH and to program cost-effective prevention and treatment strategies are urgently needed.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The author declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.