"Non-alcoholic steatohepatitis (NASH) has been associated with hepatocellular carcinoma (HCC) often arising in histologically advanced disease when steatohepatitis is not active (cryptogenic cirrhosis). Our objective was to characterize patients with HCC and active, histologically defined steatohepatitis," scientists writing in the Brazilian Journal of Medical and Biological Research report (see also Hepatocellular Cancer).

"Among 394 patients with HCC detected by ultrasound imaging over 8 years and staged by the Barcelona Clinic Liver Cancer (BCLC) criteria, we identified 7 cases (1.7%) with HCC occurring in the setting of active biopsy-proven NASH. All were negative for other liver diseases such as hepatitis C, hepatitis B, autoimmune hepatitis, Wilson disease, and hemochromatosis. The patients (4 males and 3 females, age 63 +/- 13 years) were either overweight (4) or obese (3); 57% were diabetic and 28.5% had dyslipidemia. Cirrhosis was present in 6 of 7 patients, but 1 patient had well-differentiated HCC in the setting of NASH without cirrhosis (fibrosis stage 1) based on repeated liver biopsies, the absence of portal hypertension by clinical and radiographic evaluations and by direct surgical inspection. Among the cirrhotic patients, 71.4% were clinically staged as Child A and 14.2% as Child B. Tumor size ranged from 1.0 to 5.2 cm and 5 of 7 patients were classified as early stage; 46% of all nodules were hyper-echoic and 57% were <3 cm. HCC was well differentiated in 1/6 and moderately differentiated in 5/6. Alpha-fetoprotein was <100 ng/mL in all patients. HCC in patients with active steatohepatitis is often multifocal, may precede clinically advanced disease and occurs without diagnostic levels of alpha-fetoprotein. Importantly, HCC may occur in NASH in the absence of cirrhosis," wrote A.L. Chagas and colleagues, University of Sao Paulo, Medical Department.

The researchers concluded: "More aggressive screening of NASH patients may be warranted."

Chagas and colleagues published their study in Brazilian Journal of Medical and Biological Research (Does hepatocellular carcinoma in non-alcoholic steatohepatitis exist in cirrhotic and non-cirrhotic patients? Brazilian Journal of Medical and Biological Research, 2009;42(10):958-962).

Additional information can be obtained by contacting C.P.M.S. Oliveira, University of Sao Paulo, Faculty Medical, Dept. of Gastroenterology, Av Dr. Arnaldo 455, 3 Andar, Sala 3117, BR-01246903 Sao Paulo, Brazil.

The publisher of the Brazilian Journal of Medical and Biological Research can be contacted at: Association Bras Divulg Cientifica, Faculdade Medicina, Sala 21, 14049 Ribeirao Preto, Sao Paulo, Brazil.