The evolving role of imaging in hepatocellular carcinoma: from pathomolecular profiling to prognostic decision-making

Background: Hepatocellular carcinoma (HCC), which represents the most common type of primary liver cancer, is increasingly perceived as a complex ecosystem with marked spatial and temporal heterogeneity as well as varied sensitivities to treatment. Recent revolutions in the management of HCC, particularly the introduction of several immune checkpoint inhibitor-based regimens, are placing pressing needs on more tailored imaging-aided prognostic decision-making for individualized treatment selection beyond the current “one-size-fits-all” tumor burden measurement. Summary: With an accumulating number of advanced imaging and artificial intelligence techniques bridging the gap between preclinical and clinical applications, the role of imaging in HCC is rapidly expanding from conventional surveillance, diagnosis, staging, and treatment-response evaluation to personalized pathomolecular profiling, prognostication, and therapeutic decision-making. Ultimately, imaging may direct the selection of treatment modalities precisely tailored to individual patients and tumors. Key Messages: In this review, we describe the evolving role of imaging in the noninvasive assessment of key pathomolecular drivers of outcomes in HCC, outline the applications of imaging in prognostication, risk stratification, and selection of major treatment approaches, as well as discuss unmet needs and potential future directions.