Clinical features and management issues of NAFLD-related HCC: what we know so far

ABSTRACT

Introduction

Nonalcoholic fatty liver disease (NAFLD) is replacing viral hepatitis as the leading cause of chronic liver disease and hepatocellular carcinoma (HCC) in many Western countries. NAFLD-associated HCC usually affects older patients with multiple comorbidities, frequently develops in the absence of cirrhosis, and is often diagnosed later with worse chance of survival. The worse prognosis is also due to limited surveillance strategies and a lower efficacy of standard treatments.

Areas covered

We evaluate the available literature to understand the current surveillance strategies and treatment limitations in the workup of NAFLD-associated HCC, focusing on the differences with HCC associated with other liver diseases.

Expert opinion

In this review we discuss epidemiology and risk factors for HCC in NAFLD patients and address key HCC surveillance and management issues. Although most data are still preliminary, the detection of non-cirrhotic NAFLD patients at increased risk for HCC and the potential adoption of novel screening tools could lead to accurate and suitable HCC surveillance and management strategies for NAFLD patients.

KEYWORDS:

• Nonalcoholic fatty liver disease
• nonalcoholic steatohepatitis
• hepatocellular carcinoma
• risk factors
• surveillance
• metabolic syndrome
• screening

Article highlights

• NAFLD is becoming one of the leading causes of HCC worldwide.

• The phenotypic characteristics of patients with NAFLD who are diagnosed with HCC are different from patients with virus-related HCC as they are older, with more comorbidities and at a later stage.

• A clinically relevant proportion of NAFLD-associated HCC occurs in non-cirrhotic patients.

• Current HCC screening methods are often inadequate in patients with NAFLD. New cheap and widely available biomarkers are under development to better identify patients at risk.

• According to current treatment allocation systems, patients with NAFLD-associated HCC are more often candidates for systemic treatment, but increased survival has not been demonstrated in these patients unlike patients with other liver diseases.

• New screening methods and treatments are desperately needed to improve overall survival in patients with NAFLD-associated HCC.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or mending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author Contributions

Conceptualization, N. Pugliese, A. Aghemo, A. Lleo; writing—original draft preparation, N. Pugliese, L. Alfarone, I. Arcari, S. Giugliano, T.L. Parigi; writing review and editing, M. Rescigno, A. Aghemo, A. Lleo. All authors have read and agreed to the published version of the manuscript.

Additional information

Funding

This paper was not funded.