HCC in MASLD: radiological appearance, diagnosis and treatment

Metabolic dysfunction-associated steatotic liver disease (MASLD) and its inflammatory form, metabolic dysfunction-associated steatohepatitis (MASH), are emerging as leading causes of hepatocellular carcinoma (HCC) development. This has important implications for evaluating patients with these conditions, including the potential for early diagnosis through screening techniques. Imaging techniques for the noninvasive diagnosis of HCC in the context of MASLD also present unique considerations. Notably, HCC development in patients without cirrhosis is more frequent in MASLD compared to other chronic liver disease etiologies. Moreover, the presence of liver steatosis, a common feature in MASLD patients, can modify the radiological appearance of the liver, giving HCC in MASLD/MASH uncommon imaging characteristics. Additionally, certain histological subtypes, particularly the steatohepatitic HCC, are more prevalent in MASLD/MASH, which may influence both diagnostic strategies and therapeutic decisions in these patients. This review article focuses on the radiological characteristics of HCC developed in patients with MASLD/MASH. It specifically addresses the roles of screening and surveillance, the radiological features of HCC in MASLD/MASH, the histological subtypes associated with these conditions, and the impact of imaging on treatment decisions. Finally, a brief summary of future directions and the role of new technologies in HCC diagnosis within the context of MASLD is provided.