Lower recurrence after ablation for MASLD-related versus alcohol-related hepatocellular carcinoma

Backgrounds/Aims: Non-B non-C hepatocellular carcinoma (NBNC-HCC) encompasses metabolic dysfunction-associated steatotic liver disease (MASLD), MASLD with increased alcohol intake (MetALD), and alcohol-related liver disease (ALD). We examined whether etiology is associated with recurrence after curative-intent ablation. Methods: We retrospectively analyzed 129 consecutive patients who underwent curative-intent ablation (with neoadjuvant transarterial chemoembolization in 36%) between 2011 and 2024 (MASLD 47; MetALD 21; ALD 61) after excluding two unclassifiable patients. Alcohol intake was categorized pragmatically as <=20, >20-60, or >60 g/day irrespective of sex, and the primary comparison was MASLD versus ALD. First recurrence was analyzed with a Fine-Gray model, treating death without recurrence as a competing event. Results: MASLD carried a lower recurrence hazard than ALD (adjusted subdistribution hazard ratio [sHR] 0.46, 95% CI 0.23-0.90; p=0.023). The association was present before adjustment (sHR 0.59; p=0.043) and strengthened after age adjustment, indicating negative confounding by age. Cause-specific and recurrence-free survival analyses were concordant. In exploratory analyses, local tumor progression showed no clear etiologic difference, whereas non-local recurrence was lower in MASLD (adjusted sHR 0.48; p=0.010); MetALD and ALD did not differ. Conclusions: A metabolic (MASLD) rather than alcohol-related (ALD) etiology was associated with lower post-ablation recurrence, localized to non-local rather than local recurrence. Given the pragmatic classification, follow-up imbalance, and possible residual confounding, this finding is hypothesis-generating and requires confirmation in larger, multicenter cohorts.