Accumulation of Lipid Droplets as an Underlying Cause of the Progression of Fatty Liver Disease to Liver Cancer

Prior treatment

• The SERENA study, any prior diagnosis of HCC before the study start date or a medical prognosis of less than two years results in exclusion.
• Prospective participants are excluded if they present with liver diseases of known etiologies other than MASLD, including viral, autoimmune, or purely alcoholic cirrhosis. Genetic liver diseases associated with high HCC risk (e.g., Wilson's disease, Hemochromatosis) and the presence of non-HCC hepatic malignancies, such as cholangiocarcinoma or secondary metastases, are also grounds for exclusion. Furthermore, patients are ineligible if they suffer from severe concurrent comorbidities-such as advanced renal or heart failure or systemic infections-that could interfere with study compliance or data interpretation. Finally, the ongoing use of steatogenic medications remains a strict exclusion criterion for this cohort.

Other illness

• The Retrospective, patients with an alcohol intake exceeding 60/40 g/day (M/F) or those with diagnosed genetic liver conditions-such as hereditary hemochromatosis, Wilson's disease, or Alpha-1 Antitrypsin deficiency-are excluded due to their increased baseline risk for HCC. Additionally, the use of medications known to induce secondary steatosis is a disqualifying factor.

• The retrospective cohort consists of patients previously enrolled in the SERENA, REASON, REVEAL, FOGS, and LIVER BIBLE studies who have provided informed consent for the use of their data.
• In the SERENA study, inclusion is restricted to patients aged 45-75 with a diagnosis of MASLD, MetALD, or cryptogenic SLD, showing evidence of F3-F4 fibrosis or cirrhosis through histology, imaging, or non-invasive markers (stiffness \>7.9 kPa).
• High-risk profiles, such as those with a family history of HCC or specific genetic variants (PNPLA3, TM6SF2, MBOAT7), are also included.
• The REASON and REVEAL studies contribute adult patients (≥18 years) who underwent liver biopsies for suspected NASH, liver resections for HCC or other lesions, or whole liver explants.
• The FOGS study includes individuals aged 14-80 who specifically do not present with MASLD, MetALD, or cryptogenic SLD.
• The LIVER BIBLE study provides a control group of blood donors (40-65 years) who are overweight or obese and present at least two metabolic risk factors such as hypertension, dyslipidemia, or impaired fasting glucose.
• The prospective cohort is divided into two distinct groups: a healthy control population and a MASLD/HCC population. Healthy controls must be at least 18 years old with no clinical or imaging evidence of liver disease, no significant metabolic disorders (such as diabetes or severe obesity with BMI \>30), and normal liver function tests. Their alcohol consumption must remain below 20g/day for women and 30g/day for men. The MASLD/HCC population includes adults with a confirmed diagnosis of MASLD or MetALD via imaging or histology. This group encompasses the full spectrum of the disease, from simple steatosis to advanced fibrosis, cirrhosis, and HCC. HCC cases must be diagnosed according to AASLD/EASL guidelines and staged using the BCLC system.
• All prospective participants must provide signed informed consent and have comprehensive clinical and laboratory data available.