Real-Life Clinical Use and Outcomes of Fusion Imaging-Guided Percutaneous Microwave Ablation of Hepatocellular Carcinoma: Experience from Two Italian Centers

<b>Background:</b> Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. Percutaneous thermal ablation is an effective treatment, but standard ultrasound (US) guidance is limited in cases of inconspicuous nodules. Ultrasound fusion imaging (USFI), which overlays cross-sectional imaging onto real-time US is an emerging technique that improves tumor visibility and technical feasibility. This study reports real-life outcomes of USFI-guided microwave ablation (MWA) for HCC in two Italian centers. <b>Materials and Methods:</b> In this multicentric retrospective study, 56 patients with 73 poorly or non-visible HCC nodules underwent USFI-guided percutaneous MWA with no visibility or poor visibility on B-mode US. Technical success, complications, and local tumor control were evaluated, with follow-up imaging at 1 month and every 3 months thereafter. <b>Results:</b> Complete response (CR) at 1 month was observed in 78.1% of nodules, with residual disease (RD) more common in poorly visible nodules than non-visible nodules (18.1% vs. 4.2%, <i>p</i> = 0.019). During a median 13-month follow-up, local tumor progression (LTP) occurred in 9.6% of patients. No significant association was found with difficult tumor location. <b>Conclusions:</b> USFI-guided MWA is a safe and effective option for treating HCC nodules not adequately visualized with conventional US, expanding eligibility to complex cases.