Hepatocellular carcinoma (HCC) develops even in patients with hepatitisC virus (HCV) eradication by direct-acting antiviral agents. Fatty liver and metabolic dysfunction are becoming major etiologies of HCC. We aimed to evaluate the impact of metabolic dysfunction-associated steatotic liver disease (MASLD), a new definition of steatotic liver disease, on the development of HCC after HCV eradication. We enrolled 1280 elderly patients with HCV eradication and no history of HCC. We evaluated α-fetoprotein (AFP), Fibrosis-4 index and MASLD after 24weeks of sustained virological response. Decision tree analysis was used to investigate factors associated with HCC development after HCV eradication. A total of 86 patients (6.7%) developed HCC during the follow-up period (35.8±23.7months). On multivariate analysis, serum AFP level (HR 1.08, CI 1.04-1.11, P=0.0008), Fibrosis-4 index (HR 1.17, CI 1.08-1.26, P=0.0007), and MASLD (HR 3.04, CI 1.40-6.58, P=0.0125) at 24weeks of sustained virological response were independent factors associated with HCC development. In decision tree analysis, the initial classifier for HCC development was AFP ≥7ng/mL. However, in patients with AFP <7ng/mL, MASLD, rather than Fibrosis-4 index, was the classifier for HCC development. No significant difference was observed in the cumulative incidence of HCC between patients with AFP ≥7ng/mL and patients with AFP <7ng/mL and MASLD. MASLD at 24weeks of sustained virological response is a risk factor for HCC development in elderly patients with HCV eradication. Additionally, decision tree analysis revealed that MASLD was associated with HCC development, even in patients with serum AFP levels <7ng/mL.