NAFLD—which patients should have hepatocellular carcinoma surveillance?

Studies linking non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH) and cryptogenic cirrhosis to the development of hepatocellular carcinoma (HCC) began to emerge 15 years ago (1,2). A number of large registry or cohort studies have subsequently confirmed these observations in the United States (3,4), Europe (5) and the Asia Pacific (6,7). The increasing prevalence of obesity worldwide underpins this global pattern of change, with the predicted higher prevalence of NAFLD in coming years a cause for major concern (8). The characteristics and natural history of HCC on the background of NAFLD are slowly emerging, as are concerns that HCC risk in some individuals with the metabolic syndrome may be independent of the presence of cirrhosis. Presently, HCC surveillance—with bi-annual ultrasound scan (USS)—is recommended in all patients with cirrhosis who are fit to treat (9). Extending this recommendation to NAFLD patients without cirrhosis would have major cost implications and would need careful consideration.