We read with interest the recent article by Lai et al, which evaluated 12 950 patients with metabolic dysfunction-associated steatotic liver disease (MASLD) across multiple international centres with a median follow-up of 47.7 months. The study demonstrated that a Fibrosis-4 (FIB-4) Index Score ≥3.25 or liver stiffness measurement (LSM) ≥20 kPa, or LSM ≥15 kPa when used as a second step following an elevated FIB-4, identified patient subgroups with annual hepatocellular carcinoma (HCC) incidence ≥1%, justifying surveillance in these groups.1 This represents an important advance, as it implements clear cut-offs from non-invasive tests, circumventing the complexity of traditional cirrhosis diagnosis. Current guidelines recommend biannual ultrasound, with optional alpha-fetoprotein screening, only for patients with cirrhosis and generally do not endorse routine surveillance in non-cirrhotic individuals.2 3 While approximately 10%–20% of all HCC cases arise in non-cirrhotic livers, this figure is notably higher in MASLD-related HCC, reaching up to 38%.