Use of liver stiffness measurement for HCC risk stratification in metabolic dysfunction–associated steatotic liver disease

BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) is the fastest-rising cause of HCC. A third of MASLD-HCC occur in the absence of cirrhosis, but tools to predict MASLD-HCC are lacking. Our study aimed to examine whether liver stiffness measurement (LSM) is associated with HCC risk in MASLD, identify if LSM thresholds can predict HCC risk, and identify patients for cost-effective HCC surveillance. APPROACH AND RESULTS: We conducted a retrospective study of the Veterans Analysis of Liver Disease (VALID) cohort and included patients with MASLD who underwent transient elastography between May 27, 2014, and June 1, 2023. HCC incidence rates were calculated, and we fit multivariable Cox proportional models to study the association of LSM with HCC risk. Among 30,414 participants with MASLD followed over 69,974 person-years (PY), HCC risk increased by 18% with every 5 kPa increase in LSM (subdistribution hazard ratio: 1.18, 95% CI: 1.14-1.21). The annual incidence of HCC per 100 PY was 0.34 (0.24-0.49) with LSM 10-14.9, 0.45 (0.27-0.76) with LSM 15-19.9, 0.78 (0.50-1.20) for LSM 20-24.9, and 0.94 (0.68-1.29) per 100 PY with LSM ≥25 kPa. In patients with MASLD without cirrhosis or clinically significant portal hypertension, diabetes, and an LSM of ≥10 kPa, annual HCC rates were 0.46 per 100 PY (0.29-0.78), which is above the previously described threshold for cost-effectiveness for HCC surveillance. CONCLUSIONS: LSM is associated with HCC risk in MASLD. HCC surveillance should be considered in noncirrhotic MASLD with diabetes and LSM of ≥10 kPa.