Risk of HCC in Elderly Patients With MASLD: Proposal of an Effective Surveillance Strategy

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly prevalent among aging populations. OBJECTIVE: We evaluated hepatocellular carcinoma (HCC) risk across MASLD spectrum in this population and developed a nomogram to guide optimized surveillance. METHODS: Using a nationwide South Korean database, we identified participants aged ≥ 75 years undergoing health screening between 2012 and 2015. Steatotic liver disease (SLD) was classified as MASLD, MetALD (MASLD with increased alcohol intake), or alcohol-associated liver disease (ALD). Competing-risk regression for HCC risk was used to estimate adjusted subdistribution hazard ratios (a-sHRs) by SLD subtype, using Fine-Gray models. RESULTS: Among 1 088 314 participants, 34.3% had SLD (351 583 MASLD; 11 586 MetALD; 9619 ALD). The overall 5-year HCC incidence in the SLD group (0.769%) was higher compared with the non-SLD group (0.334%). It increased stepwise from MASLD (0.687%) to MetALD (1.856%) and ALD (2.443%): a-sHRs of 1.93, 2.99, and 4.35, respectively. Stratified analyses consistently demonstrated the same pattern. A nomogram incorporating age, sex, smoking, diabetes, statin use, SLD subtype, gamma-glutamyl transferase, body mass index, liver cirrhosis, and aspartate transaminase/alanine transaminase ratio was developed, with good discriminative ability. Scores of < 103 (87.7% of participants) corresponded to an annual HCC risk of < 0.2%, suggesting exemption from HCC screening, whereas scores of > 171 (0.14%) corresponded to an annual risk of > 1%, indicating the need for continuous screening. CONCLUSIONS: Elderly individuals with MASLD spectrum exhibit a significant HCC risk, with higher risk in MetALD and ALD groups. Given the very small proportion who require HCC screening, our nomogram serves as a practical tool for community-based risk stratification and optimized surveillance.