Background Patients with nonalcoholic fatty liver disease (NAFLD) are at risk of developing hepatocellular carcinoma (HCC), but the magnitude of the association still needs to be determined to define the need for a specific surveillance strategy. Methods We based our assessment on a previously published review by White et al (1992-2011) and on a systematic review(2012-2017). Results The new search identified 328 abstracts. Combining both eras (1992-2011 and 2012-2017), 25 studies were included in the analysis. Four were prospective, 2 described a retrospective analysis of a prospective database, and the others were retrospective. All studies were published after 2004, but the inclusion period of half of them ended before the year 2000. Studies showed variation in the definition of NAFLD, in the incidence of fibrosis/cirrhosis, in the presence of comorbidities (potentially affecting HCC incidence), and in the type and duration of screening. Considering only studies strictly including patients with or without cirrhosis, the reported incidence of HCC in NAFLD patients with cirrhosis was between 6.7 and 15% at 5 to 10 years, whereas the incidence in NAFLD patients without cirrhosis was 2.7% at 10 years and 23 per 100 000 person-years. Conclusions Hepatocellular carcinoma screening in NAFLD patients with cirrhosis is mandatory. However, the currently observed low (and insufficiently documented) incidence of HCC in NAFLD patients without cirrhosis does not justify a systematic surveillance. Research efforts should focus on developing a score, which could aid the clinician in identifying NAFLD patients without cirrhosis who are at higher risk of developing HCC.
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