title: Hepatocellular Carcinoma in the Setting of Non-cirrhotic Nonalcoholic Fatty Liver Disease and the Metabolic Syndrome: US Experience.
abstract: BACKGROUND
  Type 2 diabetes mellitus, obesity, and the metabolic syndrome (MS) have been growing in prevalence in the USA and are independent risk factors for the development of hepatocellular carcinoma (HCC). Nonalcoholic fatty liver disease (NAFLD), the hepatic manifestation of the MS, with or without nonalcoholic steatohepatitis (NASH) can predispose to HCC in the absence of cirrhosis or advanced fibrosis. Nevertheless, the US literature investigating non-cirrhotic HCC in the setting of NAFLD/NASH and MS is lacking.
  
  
  OBJECTIVE
  To describe a retrospective case series of patients who developed HCC without cirrhosis in the setting of NAFLD/NASH or features of the MS.
  
  
  METHODS
  We identified NAFLD/NASH-associated HCC cases arising in the absence of cirrhosis between January 2010 and September 2012 from a tumor board database at Brooke Army Medical Center (BAMC).
  
  
  RESULTS
  Of 44 cases of HCC reviewed, six cases of non-cirrhotic HCC associated with NAFLD/NASH and/or MS were identified. Only one patient underwent partial hepatectomy with curative intent. The other five might have been candidates for potential curative partial hepatectomy or liver transplantation had they been diagnosed earlier.
  
  
  CONCLUSIONS
  Our case series highlights the development of NAFLD/NASH and MS-associated HCC in the absence of cirrhosis in the US population and raises the important question of HCC screening for this at-risk group.
authors.affiliation: Division of Gastroenterology and Hepatology, Liver Transplant Program, Stanford University School of Medicine, 750 Welch Road, Suite #210, Stanford, CA, 94304, USA. rperumpail@gmail.com.
authors.forename: Ryan B
authors.initials: RB
authors.lastname: Perumpail
authors.affiliation: Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital Campus, 1411 East 31st Street, Oakland, CA, 94602, USA. rowong@alamedahealthsystem.org.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Wong
authors.affiliation: Division of Gastroenterology and Hepatology, Liver Transplant Program, Stanford University School of Medicine, 750 Welch Road, Suite #210, Stanford, CA, 94304, USA. aijazahmed@stanford.edu.
authors.forename: Aijaz
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: Division of Gastroenterology, San Antonio Military Medical Center, 3841 Roger Brooke Drive, Fort Sam Houston, TX, 78234, USA. stephen.a.harrison.mil@mail.mil.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Harrison
mesh_terms: D017677:Age Distribution; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D015331:Cohort Studies; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D006801:Humans; D015994:Incidence; D008113:Liver Neoplasms / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D008297:Male; D024821:Metabolic Syndrome / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D017678:Sex Distribution; D015996:Survival Rate; D014481:United States / Q000453:epidemiology
keywords: Hepatocellular carcinoma; Metabolic syndrome; NAFLD; NASH; Nonalcoholic fatty liver disease; Nonalcoholic steatohepatitis