Surgical Implications for Nonalcoholic Steatohepatitis-Related Hepatocellular Carcinoma

Abstract

Hepatocellular carcinoma (HCC) is an aggressive form of liver cancer that arises in a background of chronic hepatic injury. Metabolic syndrome-associated fatty liver disease (MAFLD) and its severe form, nonalcoholic steatohepatitis (NASH), are increasingly common mechanisms for new HCC cases. NASH-HCC patients are frequently obese and medically complex, posing challenges for clinical management. In this review, we discuss NASH-specific challenges and the associated implications, including benefits of minimally invasive operative approaches in obese patients; the value of y90 as a locoregional therapy; and the roles of weight loss and immunotherapy in disease management. The relevant literature was identified through queries of PubMed, Google Scholar, and clinicaltrials.gov. Provider understanding of clinical nuances specific to NASH-HCC can improve treatment strategy and patient outcomes.

Keywords: hepatic resection; hepatocellular carcinoma; metabolic syndrome; nonalcoholic steatohepatitis; obesity.

Figure 1

An Overview of NASH-HCC Development and Treatment Options. (A) The disease progression of obesity to MAFLD with the subsequent development of NASH and potential HCC. MAFLD is present in 90% of patients with obesity. Of these patients, 20–30% go on to develop NASH. Of those who develop NASH-HCC, 35–40% will not have underlying cirrhosis. (B) Treatment options for NASH-HCC. Locoregional therapies include ablation, y90, and TACE. Surgical interventions include resection via partial hepatectomy versus orthotopic liver transplantation. * = Resection has a higher rate of recurrence within 5 years compared to transplantation, with rates listed above. Systemic therapies include immune checkpoint inhibitors. Abbreviations: MAFLD: metabolic syndrome-associated fatty liver disease, NASH: nonalcoholic steatohepatitis, HCC: hepatocellular carcinoma, y90: yttrium 90, TACE: transarterial chemoembolization.