Comparison of patients with HCC with and without MASLD after surgical resection

The prognostic impact of metabolic dysfunction-associated steatotic liver disease (MASLD) on hepatocellular carcinoma (HCC) after surgical resection remains uncertain. In this study, we compared the clinicopathological features and prognoses of patients with HCC according to MASLD status.

We retrospectively analyzed 906 treatment-naïve patients with HCC undergoing curative resection between 2016 and 2022. Based on nontumor liver histology, patients were categorized as non-MASLD (n = 496), MASLD without metabolic dysfunction-associated steatohepatitis (MASH; n = 337), or MASH (n = 73). Propensity score (PS) overlap weighting was performed to balance groups. The primary endpoint was overall survival (OS). Multivariate Cox proportional hazards models were used to identify prognosis predictors.

Patients with MASLD and HCC had higher BMI, more cardiometabolic risk factors (CMRFs), higher serum albumin, lower aspartate aminotransferase levels, lower platelet counts, earlier tumor stages, and less microvascular invasion compared with the non-MASLD group. During a median follow-up of 67.8 months, 242 deaths occurred. Patients with MASLD had significantly better 5-year OS compared with those without MASLD (76.9% vs. 71.1%; p = 0.023). Notably, the group with MASLD but not MASH had the highest 5-year OS (79.6%), whereas the 5-year OS of the MASH subgroup (64.7%) was comparable to that of the non-MASLD group. CMRFs alone did not affect OS. In a multivariate analysis following PS overlap weighting, MASLD without MASH showed improved OS (adjusted hazard ratio [adj-HR], 0.703; 95% CI, 0.500-0.987; p = 0.042), whereas MASH independently predicted poorer OS (adj-HR, 1.950; 95% CI, 1.154-3.296; p = 0.013).

Simple steatosis (MASLD without MASH) confers a survival advantage for patients with HCC following surgical resection, whereas progression to MASH negated this benefit and led to outcomes that aligned with those of the non-MASLD group.

The rising prevalence of MASLD has made it a major etiology of HCC, yet its prognostic significance remains debated. Our study demonstrates that simple steatosis confers a clear survival benefit after hepatectomy, whereas steatohepatitis negates this advantage. By contrast, the mere presence of CMRFs does not alter survival or recurrence risk. These insights highlight the need to incorporate histological phenotyping by differentiating simple steatosis from inflammatory steatohepatitis into postoperative management protocols to refine risk stratification and optimize surveillance strategies for patients with HCC.