From platforms to pathways: imaging innovation, quantitative biomarkers, and clinical translation in hepatocellular carcinoma

Abstract

Imaging is central to nearly every stage of hepatocellular carcinoma (HCC) management, from surveillance and noninvasive diagnosis to staging, locoregional therapy planning, treatment response assessment, and recurrence monitoring. Recent progress begins with imaging hardware but depends just as much on acquisition design, reconstruction, quantification, harmonization, and workflow integration. This narrative review examines how ultrasound, computed tomography (CT), magnetic resonance imaging (MRI), and nuclear or hybrid imaging have changed HCC care, while separating clinically established tools from technologies that remain largely translational. Ultrasound has advanced beyond screening through contrast-enhanced ultrasound (CEUS), Kupffer-phase agents, elastography, and fusion navigation. CT has progressed through spectral imaging, deep learning reconstruction, and cone-beam guidance, whereas photon-counting CT remains promising but early. MRI has consolidated its role through 3T platforms, multichannel coils, accelerated acquisitions, hepatobiliary contrast agents, diffusion-based imaging, magnetic resonance elastography (MRE), and abbreviated protocols. Positron emission tomography remains constrained by tracer biology in early HCC, although novel tracers and positron emission tomography (PET)/MRI broaden selected applications. Across modalities, imaging advances are most useful when acquisition and biomarker extraction are reproducible enough to support the Liver Imaging Reporting and Data System (LI-RADS), treatment response assessment, and downstream clinical decisions. Evidence is strongest for CEUS, gadoxetic acid-enhanced MRI, MRE for selected risk questions, and image-guided interventional platforms, whereas spectral CT has growing selected-use evidence but still requires broader standardization of quantitative thresholds. By contrast, radiomics, deep learning, advanced diffusion models, photon-counting CT, and theranostic-oriented molecular imaging still face important barriers related to external validity, harmonization, and clinical qualification.

Keywords

Hepatocellular carcinoma / quantitative imaging / imaging hardware / treatment response / radiomics

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