Prognostic and predictive imaging markers of hepatocellular carcinoma: a pictorial essay

Hepatocellular carcinoma (HCC) encompasses a wide array of histopathologic and genetic features that can be broadly categorized as proliferative or non-proliferative HCC to reflect tumor aggressiveness. However, accurately characterizing tumor behavior remains challenging due to the biologic heterogeneity of HCC and limited access to tissue samples. Currently, imaging is used for the diagnosis of HCC using the Liver Imaging Reporting and Data System (LI-RADS) without histologic confirmation in most cases. Emerging data suggest that imaging can provide clinical insight beyond diagnosis and predict patient outcomes by identifying key prognostic features, including those not yet integrated in LI-RADS. Certain CT and MRI features correlate with proliferative and non-proliferative HCC, and may yield prognostic information. Imaging findings such as tumor size, multifocality, and low apparent diffusion coefficient (ADC) have also been associated with microvascular invasion-an independent marker of poor prognosis. Growing data support the role of imaging in predicting treatment responsiveness before therapy initiation, which may influence the selection of a therapeutic agent. The radiologist can offer key clinical information by understanding and describing the prognostic and predictive features in HCC imaging. CRITICAL RELEVANCE STATEMENT: This study provides radiologists with a comprehensive summary of imaging findings associated with HCC prognosis, treatment responsiveness, and microvascular invasion. KEY POINTS: Hepatocellular carcinoma (HCC) is a heterogeneous cancer leading to challenges in diagnosis and management. Tumors can exhibit imaging features associated with proliferative or non-proliferative HCC. Key imaging features can help predict tumor aggressiveness and treatment responsiveness before the therapy is applied. Further research leveraging molecular data and applying machine learning models can improve our understanding of HCC prognostication.