{"paper_id":"25dc0ff8-2fc5-47e6-8a11-d6f41b63f908","body_text":"Evaluation of the efficacy of CT/MR-Ultrasound Fusion Imaging in Ablation of Hepatocellular Carcinoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Evaluation of the efficacy of CT/MR-Ultrasound Fusion Imaging in Ablation of Hepatocellular Carcinoma Lin Wang, Xuqi He, Kai Li, Qingjing Zeng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6909462/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 11 You are reading this latest preprint version Abstract Objective To investigate the efficacy and safety of intraoperative CT/magnetic resonance-ultrasound (CT/MR-US) fusion imaging in thermal ablation therapy for hepatocellular carcinoma (HCC). Methods A total of 281 HCC patients (231 males and 50 females, median age 58 years) meeting the Milan criteria were retrospectively enrolled from January 2023 to December 2024. All patients underwent percutaneous thermal ablation guided by intraoperative CT/MR-US fusion imaging. Technical efficacy and major complications were calculated. Overall survival (OS), cumulative local tumor progression (LTP), and tumor-free survival(TFS) were estimated using the Kaplan-Meier method. Results Among 463 nodules in 281 patients, all procedures were successfully completed. The technical and clinical success rates were both 100% (463/463). The postoperative complication rate was 3.6% (10/281). During a median follow-up of 5.97 months, the OS rate was 99.6%, with an LTP rate of 0.86% (4/463) and an intrahepatic recurrence rate of 16.01% (45/281). The median TFS was 19.87 months. Conclusion CT/MR-US fusion imaging is an effective technique for HCC thermal ablation, demonstrating high success rates, low complications, and favorable short-term outcomes. It is particularly applicable for HCC patients meeting the Milan criteria. Further validation is required for its long-term efficacy and applicability in advanced-stage HCC. Biological sciences/Cancer Health sciences/Medical research/Outcomes research Radiofrequency Ablation Liver Neoplasms CT/MR-US Fusion Imaging Figures Figure 1 Figure 2 Introduction Hepatocellular carcinoma is one of the common malignant tumors in clinical practice. Currently, its incidence rate ranks sixth in the world and tumor-related mortality rate ranks fourth. World Health Organization (WHO) data show that in 2022 the incidence rate of liver cancer rises to the 4th place in China, and the mortality rate remains in the 2nd place(1). The WHO International Agency for Research on Cancer (IARC) estimates that in 2022, there will be about 870,000 new cases of liver cancer and 760,000 deaths worldwide. Among liver cancer incidence, hepatocellular carcinoma (HCC) is the most common type of liver cancer, accounting for about 80% of all liver cancer incidence(2). Because the early onset of HCC is insidious and the clinical manifestations are not obvious, most patients are in the middle to late stage after diagnosis, and the prognosis is poor. Globally, the 5-year survival rate of HCC is 18%, and the 5-year survival rate of HCC in China is even more worrisome, only 12%, resulting in tremendous social and economic pressure. Liver transplantation, surgical resection and ablation therapy are the first-line treatment modalities for early-stage HCC, hepatic artery chemoembolization is the mainstay for intermediate-stage HCC, and systemic therapy is the mainstay for advanced-stage HCC. With the continuous development and improvement of image-guided technology, thermal ablation therapy has been widely and deeply applied in early-stage HCC, especially in patients who cannot tolerate surgical treatment and are of advanced age, and has achieved clinical efficacy comparable to that of surgery, and has the advantages of lower complication rate, more minimally invasive treatment process, and less medical cost(3). Meanwhile, thermal ablation has not only achieved good clinical efficacy in controlling tumor growth through palliative tumor reduction in middle and advanced HCC, but also provided synergistic effect for systemic therapy. Therefore, image-guided thermal ablation plays an increasingly important role in the treatment of HCC(4). Although ultrasound (US), a commonly used image guidance tool, has the advantages of low cost, convenience, real-time display, and no radiation, the use of US guidance and monitoring during percutaneous thermal ablation may present challenges such as the difficulty of clearly displaying the borders of deep tumors/small tumor lesions, gas interference, and so on. Therefore, to overcome the aforementioned limitations of ultrasound guidance and monitoring during percutaneous thermal ablation, a CT/ MR-US fusion imaging system has been developed and introduced into clinical practice for the thermal ablation of HCC, which allows for the simultaneous fusion of real-time US images with corresponding CT or MR reconstructed images by means of an electromagnetic localization system and three-dimensional reconstruction data. It has been shown that CT/MR-US can help assess the adequacy of ablation and guide intraoperative adjuvant ablation, thereby improving the technical success and technical effectiveness of hepatic thermal ablation(5). The purpose of this retrospective study was to investigate the efficacy and safety of intraoperative CT/MR-US fusion imaging in the thermal ablation treatment of HCC. Materials and methods Patients The data of patients who underwent CT/MR-US-guided thermal ablation treatment at our hospital between January 2023 and December 2024 were retrospectively analyzed. The inclusion criteria were as follows: (1) pathological or clinical diagnosis of HCC; (2) the size and number of patients' HCC met the Milan criteria (no single tumor exceeding 5 cm in diameter or fewer than 3 tumors in more multiple tumors and with a maximal diameter of no more than 3 cm, with no phenomenon of large-vessel invasion, and with no phenomenon of lymph node or extra-hepatic metastasis); (3) intraprocedural evaluation of efficacy using CT/MR-US; (4) Patients underwent CT/MR enhancement evaluation within 1 month after ablation and were followed up regularly; (5) Liver function Child-Pugh grade A or B. Exclusion criteria: (1) patients with missing or incomplete data; (2) patients with other malignant tumors or serious complications affecting the efficacy judgment. (This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of The Third Affiliated Hospital of Sun Yat-sen University. Due to the retrospective nature of the study, the requirement for written informed consent was waived by the ethics committee. ) Equipment and Thermal Ablation Process 1.Instruments MyLab TWICE, MyLab ClassC color Doppler ultrasound diagnostic instrument (Esaote, Italy), the probe was an abdominal convex array probe CA541 (probe frequency 1 ~ 8MHz). Water-cooled microwave ablator, 15G water-circulating internal-cooled microwave antenna, with the output power set at 60W, and the ablation time of each needle was 3–5 min. AJ-500A radiofrequency ablation instrument (Angel Medical Technology(Nanjing) Co.;LTD), 17G internal cooling type radiofrequency ablation with needle electrodes (150 − 20 specifications), the length of the bare end of the 2cm, the use of pulse ablation mode, the output power is set to the maximum value (150W), the ablation time of each needle 8 ~ 12min 2.Ablation method The operation was performed by a physician with more than 5 years of experience in ultrasound-guided thermal ablation of liver tumors. All patients were put under general anesthesia by tracheal intubation and inhalation, routinely disinfected and toweling, and underwent percutaneous transhepatic thermal ablation of tumors under ultrasound guidance, firstly, ablating the base of the tumors with puncture needles, and then ablating the pericardium and proximal portion of the tumors with puncture needles one by one, and ultimately, achieving the total ablation of all the tumors. Intraoperative ultrasound closely monitors the relationship between the tip of the ablation needle and the position of the heart. Immediately after ablation, ultrasonography is performed to assess the efficacy of the ablation, to determine the extent of ablation and the presence of active bleeding, and according to the results of the assessment, supplemental ablation or needle cauterization is performed to stop bleeding, so as to ensure that the lesion is completely ablated without damaging the heart. Intraoperative monitoring of changes in cardiac-related indicators and adjustment of anesthesia medication were made accordingly. Record the occurrence of intraoperative complications. 3. Combined aids For those with poor acoustic window display use artificial ascites (raphe impact) artificial pleural fluid or one-lung ventilation (lung air impact) to assist, for acoustic window improvement and protection of neighboring structures, and to determine the presence of hemorrhagic manifestations through the drainage fluid. For lesions poorly displayed by two-dimensional ultrasound, intraoperative puncture guidance and monitoring were performed using ultrasonography or fusion imaging ultrasonography. 4.Efficacy monitoring and follow-up All patients underwent ultrasonography immediately after ablation to assess the extent of ablation and bleeding from the needle tracts, etc., and ultrasonography was performed in the first 24 h after the procedure, and the perioperative symptoms, signs and laboratory tests, such as monitoring of liver function, coagulation, and inflammation indexes were used to assess the Complications. Enhanced MRI or CT was routinely performed 1 month after surgery as the gold standard for ablation efficacy assessment. Subsequently, imaging and laboratory tests were performed every 2 to 3 months to regularly assess the occurrence of complications and tumor progression. Evaluation indicators 1.Thermal ablation technical success rate (nodule-based technical assessment): the ratio of the number of nodules achieving ablation technical success to the total number of nodules. Technical success was defined as immediate post ablation ultrasonography of the liver tumor showing complete coverage of the original tumor area without acute complications. 2.Postoperative complication rate: the ratio of the number of patients experiencing postoperative complications to the total number of patients. 3.survival analysis Survival curves were plotted using the KM (Kaplan-Meier) method with survival time in the horizontal coordinate and survival rate in the vertical coordinate. Local tumor progression (LTP): defined as the appearance of new enhancing lesions within or at the margins of the completely ablated area of the tumor on enhanced CT or MRI examination 1 month after surgery. In this study, the rate of local tumor progression was calculated based on the number of nodules, i.e., the ratio of the number of nodules in which LTP occurred to the total number of nodules. Tumor-free survival rate: the number of patients without recurrence or new tumors after treatment as a proportion of the total number of patients statistical analysis The collected data were entered into an electronic database and analyzed in strict accordance with statistical principles. Data were analyzed using SPSS statistical software, and measurements (e.g., tumor size) were expressed as mean ± standard deviation if normally distributed, or median (range) if not normally distributed; count data (e.g., recurrence rate) were expressed as frequency and percentage. Results Baseline information of patients A total of 281 patients were included in this study, with a median age of 58 years and a median length of hospitalization of 8 months; a total of 463 nodules, of which the median maximum tumor diameter of 16 mm.(Table 1 ). All patients included in the study successfully completed the surgery, and the success rate of patients' tumor ablation technique was 100% (463/463), and the effective rate of the technique was 100% (463/463). Radiofrequency ablation (RFA) was used in 36 (48.4%) patients, and radiofrequency ablation combined with microwave ablation (MWA) was used in 145 (51.6%) patients. Postoperative complication rate Of these 281 patients, 10 (3.6%) had postoperative complications including fever (n = 4), abdominal infection with gastrointestinal bleeding (n = 1), infection (n = 2), infection with peritoneal effusion (n = 1), infected fever (n = 1), and subcutaneous hematoma (n = 1), and there were no surgery-related deaths. Follow-up and survival outcomes 1. Overall survival The 281 patients included had a median follow-up of 5.97 months (range 0.40–21.60), and 1 patient died during follow-up, giving a survival rate of 99.6%.(Fig. 1 ). 2. Recurrence during follow-up Four nodules out of 463 nodules during the follow-up period were diagnosed as LTP, with an incidence of LTP of 0.86% (4/463), and the four nodules were from four patients, two of whom were diagnosed as hepatocellular carcinoma and two of whom were diagnosed as liver metastases at the time of admission; at the time of treatment, one patient was treated with combined microwave ablation therapy, and the remaining three were treated only with radiofrequency ablation therapy, and all of them were treated with a single needle. Intrahepatic recurrence occurred in 16.01% of 281 patients during follow-up (45/281), and the median tumor-free survival of the patients was 19.87 months, with a cumulative tumor-free survival rate of approximately 73.8% at one year.(Fig. 2 ). Discussion By retrospectively analyzing 281 patients with hepatocellular carcinoma treated with CT/MR-US fusion imaging-guided thermal ablation at our center, the results of this study demonstrated a high technical success rate (100%), low complication rate (3.6%), and low rate of intrahepatic recurrence (16.01%) in the treatment of hepatocellular carcinoma, as well as demonstrating good short-term survival outcomes (median follow-up 5.97 months, survival rate of 99.6%, cumulative LTP rate of 0.86%, and median tumor-free survival of 19.87 months). Technical success, cumulative LTP incidence, and intrahepatic recurrence rates turned out to be superior to the outcomes of other similar studies (100% vs. 83.8%-98.8%; 0.86% vs. 3.6%-11.9%; 16.52%-55.4%)(6–11). Ultrasound-guided thermal ablation is an important means of liver cancer treatment, which precisely applies thermal energy to tumor tissues through real-time ultrasound guidance, and uses high temperature to cause coagulative necrosis of tumor cells, so as to achieve minimally invasive eradication. However, there are certain limitations of traditional ultrasound guidance in percutaneous ablation, such as poor display of deep or small tumor boundaries and interference of gas artifacts. In recent years, the CT/MR-US fusion imaging technology has effectively compensated for the above shortcomings. This technology fuses enhanced CT or MRI images with real-time ultrasound images through a magnetic localization system, integrating the advantages of multimodal imaging and significantly improving the accuracy of tumor boundary identification. The tumor target area is pre-labeled based on CT/MR images and projected to the real-time ultrasound interface before ablation, which can accurately guide the implantation of ablation electrodes, avoiding puncture deviation and gas interference, and ensuring complete coverage of the tumor. For larger lesions, the single-needle multipoint overlapping ablation strategy can achieve tumor inactivation and reduce the risk of multi-needle operation. Single-needle ablation was used in 89.7% of the patients in this study, which not only reduces the medical cost, but also shortens the hospitalization time and reduces the physical and psychological burden of the patients. In this study, the incidence of major postoperative complications was only 3.6%, which was lower than the complication rate of conventional ultrasound-guided ablation (5%-10%)(3), and the CT/MR-US fusion imaging technology can display the ablation situation in real time, and once incomplete ablation is detected, supplemental ablation can be guided, which ensures that the ablation is complete in all the patients and reduces the risk of postoperative recurrence, and has a high value of application in the assessment of the efficacy of ultrasound-guided thermal ablation for patients with primary hepatocellular carcinoma. Despite the short median follow-up time (5.97 months), the tumor-free survival rate in this study (73.8%) was generally consistent with previous reports (70%-80%)(4), suggesting that ultrasound fusion imaging may improve short-term prognosis. However, the intrahepatic recurrence rate (16.01%) was significantly higher than the LTP rate (0.86%). LTP is mostly associated with incomplete tumor ablation therapy, while intrahepatic recurrence may originate from micrometastases or new tumors, which can be detected by examining the HBV-DNA integration pattern, the type of mutation in the p53 gene, and the pattern of heterozygous chromosomal deletions; however, the reliability of these discriminatory methods has yet to be verified(12). Although thermal ablation can inactivate visible lesions, it has limited control of microvascular invasion or satellite lesions, and combined systemic therapy (e.g., targeted or immunotherapy) may be the future direction. Although CT/MR-US/CEUS fusion imaging has significantly improved the accuracy of thermal ablation, there are still limitations in its clinical application. First, the technique is highly dependent on operator experience and requires systematic training to master core skills such as multimodal image alignment, real-time navigation, and error correction. Second, intraoperative dynamic interfering factors may affect the stability of the technique, such as changes in liver morphology due to artificial ascites intervention or surgical operation, and poor visualization of hepatic blood vessels, etc., which may lead to image alignment deviations and thus affect the judgment of ablation extent. Therefore, it is necessary to fully assess the anatomical characteristics of the patient before surgery, and combine with the dynamic calibration of enhanced images during surgery to avoid technical risks to the greatest extent possible. This study has some limitations:(1) this is a retrospective study, which may lead to missing data or measurement bias; (2) the median follow-up time was only 5.97 months, which makes it difficult to assess the long-term efficacy; (3) The additional benefit of fusion imaging could not be quantified because no control group was set up for conventional ultrasound-guided ablation (4) the included cases were early-stage hepatocellular carcinomas (meeting the Milan criteria), and the conclusions may not be applicable to for patients with mid- to late-stage disease. Overall, CT/MR-US fusion imaging is an effective technique for thermal ablation treatment of HCC and is suitable for the treatment of patients with HCC meeting the Milan criteria. Abbreviations CT/MR-US CT/Magnetic Resonance-Ultrasound HCC Hepatocellular Carcinoma OS Overall Survival LTP Cumulative Local Tumor Progression TPS Tumor-Free Survival WHO World Health Organization IARC International Agency for Research on Cancer US Although Ultrasound KM Kaplan-Meier RFA Radiofrequency Ablation MWA Microwave Ablation Declarations Author Contribution Lin Wang: Conceptualized and designed the study, conducted the imaging evaluation contributed to data analysis, and drafted the manuscript. Xuqi He: Performed data collection and contributed to manuscript revision. Kai Li: Conducted the imaging evaluation and provided critical insights into CT interpretation. Qingjing Zeng : Supervised the study, reviewed the manuscript critically for important intellectual content, and served as the corresponding author. All authors read and approved the final manuscript. Acknowledgement Thank you to the team for their dedication to this research, thank you to the editors for their review, thank you! Data Availability Statement The datasets generated and analyzed during the current study are not publicly available due to institutional data protection policies but are available from the corresponding author upon reasonable request and with the approval of the institutional ethics committee. Ethical Statement This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of The Third Affiliated Hospital of Sun Yat-sen University. Due to the retrospective nature of the study, the requirement for written informed consent was waived by the ethics committee. Patient confidentiality was strictly maintained throughout the study, and all data were anonymized before analysis. References World Health Organization. (2024, February 1). Global cancer burden growing, amidst mounting need for services. https://www.who.int/news/item/01-02-2024-global-cancer-burden-growing--amidst-mounting-need-for-services. Miao, W. G., Zhou, J. Y., & Han, R. Q. (2024). Global epidemiological patterns of hepatocellular carcinoma: A comprehensive analysis [in Chinese]. Chinese Journal of Epidemiology (Zhonghua Liu Xing Bing Xue Za Zhi), 45(6), 865-869. https://doi.org/10.3760/cma.j.cn112338-20231027-00251 Liang P, Yu J, Yu XL, Wang XH, Wei Q, Yu SY, Li HX, Sun HT, Zhang ZX, Liu HC, Cheng ZG, Han ZY. Percutaneous cooled-tip microwave ablation under ultrasound guidance for primary liver cancer: a multicentre analysis of 1363 treatment-naive lesions in 1007 patients in China. Gut. 2012 Jul;61(7):1100-1. doi: 10.1136/gutjnl-2011-300975. Epub 2011 Oct 13. PMID: 21997552. Chen Z, Xie H, Hu M, Huang T, Hu Y, Sang N, Zhao Y. Recent progress in treatment of hepatocellular carcinoma. Am J Cancer Res. 2020 Sep 1;10(9):2993-3036. PMID: 33042631; PMCID: PMC7539784. Xu E, Li K, Long Y, Luo L, Zeng Q, Tan L, He X, Huang Q, Wu Y, Zheng R. Intra-Procedural CT/MR-Ultrasound Fusion Imaging Helps to Improve Outcomes of Thermal Ablation for Hepatocellular Carcinoma: Results in 502 Nodules. Ultraschall Med. 2021 Apr;42(2):e9-e19. English. doi: 10.1055/a-1021-1616. Epub 2019 Oct 31. PMID: 31671457. Xu ZF, Xie XY, Kuang M, Liu GJ, Chen LD, Zheng YL, Lu MD. Percutaneous radiofrequency ablation of malignant liver tumors with ultrasound and CT fusion imaging guidance. J Clin Ultrasound. 2014 Jul-Aug;42(6):321-30. doi: 10.1002/jcu.22141. Epub 2014 Feb 25. PMID: 24615771. Ahn SJ, Lee JM, Lee DH, Lee SM, Yoon JH, Kim YJ, Lee JH, Yu SJ, Han JK. Real-time US-CT/MR fusion imaging for percutaneous radiofrequency ablation of hepatocellular carcinoma. J Hepatol. 2017 Feb;66(2):347-354. doi: 10.1016/j.jhep.2016.09.003. Epub 2016 Sep 17. PMID: 27650284. Song KD, Lee MW, Rhim H, Kang TW, Cha DI, Sinn DH, Lim HK. Percutaneous US/MRI Fusion-guided Radiofrequency Ablation for Recurrent Subcentimeter Hepatocellular Carcinoma: Technical Feasibility and Therapeutic Outcomes. Radiology. 2018 Sep;288(3):878-886. doi: 10.1148/radiol.2018172743. Epub 2018 Jun 19. PMID: 29916771. Huang J, Yan L, Cheng Z, Wu H, Du L, Wang J, Xu Y, Zeng Y. A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria. Ann Surg. 2010 Dec;252(6):903-12. doi: 10.1097/SLA.0b013e3181efc656. PMID: 21107100. Yu J, Yu XL, Han ZY, Cheng ZG, Liu FY, Zhai HY, Mu MJ, Liu YM, Liang P. Percutaneous cooled-probe microwave versus radiofrequency ablation in early-stage hepatocellular carcinoma: a phase III randomised controlled trial. Gut. 2017 Jun;66(6):1172-1173. doi: 10.1136/gutjnl-2016-312629. Epub 2016 Nov 24. PMID: 27884919; PMCID: PMC5532455. Shiina S, Tateishi R, Arano T, Uchino K, Enooku K, Nakagawa H, Asaoka Y, Sato T, Masuzaki R, Kondo Y, Goto T, Yoshida H, Omata M, Koike K. Radiofrequency ablation for hepatocellular carcinoma: 10-year outcome and prognostic factors. Am J Gastroenterol. 2012 Apr;107(4):569-77; quiz 578. doi: 10.1038/ajg.2011.425. Epub 2011 Dec 13. PMID: 22158026; PMCID: PMC3321437. Xia, Y., Yang, T., & Wang, K. (2021). Chinese expert consensus on prevention and treatment of postoperative recurrence in hepatocellular carcinoma after hepatectomy (2020 edition) [in Chinese]. Chinese Journal of Practical Surgery (Zhongguo Shiyong Waike Zazhi), 41(1), 20-30. https://doi.org/10.19538/j.cjps.issn1005-2208.2021.01.03 Tables Table 1: Baseline profile of patients Baseline Results Number of patients (n) 281 Sex (male/female) [n (%)] 231（82.2%）/50（17.8%） Age (years) 58（19-84） Cirrhosis (no/yes)[n (%)] 93（33.1%）/188（66.9%） AFP(ng/mL)（＜20/20-200/＞200） 215（77.6%）/39（14.1%）/23（8.3%） Diagnosis (hepatocellular carcinoma/hepatic metastases/other) 238（84.7%）/27（9.6%）/16（5.7%） Comorbidity (none/yes) 156（55.5%）/124（44.1%） Ablation technique (RFA/RFA+MWA) [n (%)] 136（48.4%）/145（51.6%） Number of needles (single/double) 252（89.7%）/29（10.3%） Number of nodules (pcs) 463 Length of hospitalization (months) Median (range) 8（2-43） Maximum tumor diameter (mm) Median (range) 16（4-57） Postoperative complications (none/yes) 271（96.4%）/10（3.6%） Additional Declarations No competing interests reported. Supplementary Files supplementaryfiles1.xlsx Supplementalfile2Reviewapprovaldocuments.pdf sdatasensitivedatachecklist.pdf Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 05 Feb, 2026 Reviews received at journal 13 Jan, 2026 Reviews received at journal 05 Jan, 2026 Reviewers agreed at journal 04 Jan, 2026 Reviewers agreed at journal 03 Jan, 2026 Reviewers agreed at journal 28 Dec, 2025 Reviewers invited by journal 19 Sep, 2025 Editor assigned by journal 16 Sep, 2025 Editor invited by journal 19 Jun, 2025 Submission checks completed at journal 18 Jun, 2025 First submitted to journal 16 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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10:23:16\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":53155,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eOverall survival curve\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6909462/v1/01bd93eb51396636f81e88a5.png\"},{\"id\":92495129,\"identity\":\"3cb13c61-5509-4089-bd18-b738168a3ff7\",\"added_by\":\"auto\",\"created_at\":\"2025-09-30 10:23:16\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":60048,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eTumor-free survival 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10:23:17\",\"extension\":\"pdf\",\"order_by\":3,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":150497,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"sdatasensitivedatachecklist.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-6909462/v1/c96544ec3f9c915229decfdd.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Evaluation of the efficacy of CT/MR-Ultrasound Fusion Imaging in Ablation of Hepatocellular Carcinoma\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eHepatocellular carcinoma is one of the common malignant tumors in clinical practice. Currently, its incidence rate ranks sixth in the world and tumor-related mortality rate ranks fourth. World Health Organization (WHO) data show that in 2022 the incidence rate of liver cancer rises to the 4th place in China, and the mortality rate remains in the 2nd place(1). The WHO International Agency for Research on Cancer (IARC) estimates that in 2022, there will be about 870,000 new cases of liver cancer and 760,000 deaths worldwide. Among liver cancer incidence, hepatocellular carcinoma (HCC) is the most common type of liver cancer, accounting for about 80% of all liver cancer incidence(2). Because the early onset of HCC is insidious and the clinical manifestations are not obvious, most patients are in the middle to late stage after diagnosis, and the prognosis is poor. Globally, the 5-year survival rate of HCC is 18%, and the 5-year survival rate of HCC in China is even more worrisome, only 12%, resulting in tremendous social and economic pressure.\\u003c/p\\u003e\\u003cp\\u003eLiver transplantation, surgical resection and ablation therapy are the first-line treatment modalities for early-stage HCC, hepatic artery chemoembolization is the mainstay for intermediate-stage HCC, and systemic therapy is the mainstay for advanced-stage HCC. With the continuous development and improvement of image-guided technology, thermal ablation therapy has been widely and deeply applied in early-stage HCC, especially in patients who cannot tolerate surgical treatment and are of advanced age, and has achieved clinical efficacy comparable to that of surgery, and has the advantages of lower complication rate, more minimally invasive treatment process, and less medical cost(3). Meanwhile, thermal ablation has not only achieved good clinical efficacy in controlling tumor growth through palliative tumor reduction in middle and advanced HCC, but also provided synergistic effect for systemic therapy. Therefore, image-guided thermal ablation plays an increasingly important role in the treatment of HCC(4).\\u003c/p\\u003e\\u003cp\\u003eAlthough ultrasound (US), a commonly used image guidance tool, has the advantages of low cost, convenience, real-time display, and no radiation, the use of US guidance and monitoring during percutaneous thermal ablation may present challenges such as the difficulty of clearly displaying the borders of deep tumors/small tumor lesions, gas interference, and so on. Therefore, to overcome the aforementioned limitations of ultrasound guidance and monitoring during percutaneous thermal ablation, a CT/ MR-US fusion imaging system has been developed and introduced into clinical practice for the thermal ablation of HCC, which allows for the simultaneous fusion of real-time US images with corresponding CT or MR reconstructed images by means of an electromagnetic localization system and three-dimensional reconstruction data. It has been shown that CT/MR-US can help assess the adequacy of ablation and guide intraoperative adjuvant ablation, thereby improving the technical success and technical effectiveness of hepatic thermal ablation(5). The purpose of this retrospective study was to investigate the efficacy and safety of intraoperative CT/MR-US fusion imaging in the thermal ablation treatment of HCC.\\u003c/p\\u003e\"},{\"header\":\"Materials and methods\",\"content\":\"\\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003ePatients\\u003c/h2\\u003e\\n \\u003cp\\u003eThe data of patients who underwent CT/MR-US-guided thermal ablation treatment at our hospital between January 2023 and December 2024 were retrospectively analyzed. The inclusion criteria were as follows: (1) pathological or clinical diagnosis of HCC; (2) the size and number of patients\\u0026apos; HCC met the Milan criteria (no single tumor exceeding 5 cm in diameter or fewer than 3 tumors in more multiple tumors and with a maximal diameter of no more than 3 cm, with no phenomenon of large-vessel invasion, and with no phenomenon of lymph node or extra-hepatic metastasis); (3) intraprocedural evaluation of efficacy using CT/MR-US; (4) Patients underwent CT/MR enhancement evaluation within 1 month after ablation and were followed up regularly; (5) Liver function Child-Pugh grade A or B. Exclusion criteria: (1) patients with missing or incomplete data; (2) patients with other malignant tumors or serious complications affecting the efficacy judgment.\\u003c/p\\u003e\\n \\u003cp\\u003e(This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of The Third Affiliated Hospital of Sun Yat-sen University. Due to the retrospective nature of the study, the requirement for written informed consent was waived by the ethics committee. )\\u003c/p\\u003e\\n\\u003c/div\\u003e\\n\\u003ch3\\u003eEquipment and Thermal Ablation Process\\u003c/h3\\u003e\\n\\u003cp\\u003e1.Instruments\\u003c/p\\u003e\\n\\u003cp\\u003eMyLab TWICE, MyLab ClassC color Doppler ultrasound diagnostic instrument (Esaote, Italy), the probe was an abdominal convex array probe CA541 (probe frequency 1\\u0026thinsp;~\\u0026thinsp;8MHz). Water-cooled microwave ablator, 15G water-circulating internal-cooled microwave antenna, with the output power set at 60W, and the ablation time of each needle was 3\\u0026ndash;5 min. AJ-500A radiofrequency ablation instrument (Angel Medical Technology(Nanjing) Co.;LTD), 17G internal cooling type radiofrequency ablation with needle electrodes (150\\u0026thinsp;\\u0026minus;\\u0026thinsp;20 specifications), the length of the bare end of the 2cm, the use of pulse ablation mode, the output power is set to the maximum value (150W), the ablation time of each needle 8\\u0026thinsp;~\\u0026thinsp;12min\\u003c/p\\u003e\\n\\u003cp\\u003e2.Ablation method\\u003c/p\\u003e\\n\\u003cp\\u003eThe operation was performed by a physician with more than 5 years of experience in ultrasound-guided thermal ablation of liver tumors. All patients were put under general anesthesia by tracheal intubation and inhalation, routinely disinfected and toweling, and underwent percutaneous transhepatic thermal ablation of tumors under ultrasound guidance, firstly, ablating the base of the tumors with puncture needles, and then ablating the pericardium and proximal portion of the tumors with puncture needles one by one, and ultimately, achieving the total ablation of all the tumors. Intraoperative ultrasound closely monitors the relationship between the tip of the ablation needle and the position of the heart. Immediately after ablation, ultrasonography is performed to assess the efficacy of the ablation, to determine the extent of ablation and the presence of active bleeding, and according to the results of the assessment, supplemental ablation or needle cauterization is performed to stop bleeding, so as to ensure that the lesion is completely ablated without damaging the heart. Intraoperative monitoring of changes in cardiac-related indicators and adjustment of anesthesia medication were made accordingly. Record the occurrence of intraoperative complications.\\u003c/p\\u003e\\n\\u003cp\\u003e3. Combined aids\\u003c/p\\u003e\\n\\u003cp\\u003eFor those with poor acoustic window display use artificial ascites (raphe impact) artificial pleural fluid or one-lung ventilation (lung air impact) to assist, for acoustic window improvement and protection of neighboring structures, and to determine the presence of hemorrhagic manifestations through the drainage fluid. For lesions poorly displayed by two-dimensional ultrasound, intraoperative puncture guidance and monitoring were performed using ultrasonography or fusion imaging ultrasonography.\\u003c/p\\u003e\\n\\u003cp\\u003e4.Efficacy monitoring and follow-up\\u003c/p\\u003e\\n\\u003cp\\u003eAll patients underwent ultrasonography immediately after ablation to assess the extent of ablation and bleeding from the needle tracts, etc., and ultrasonography was performed in the first 24 h after the procedure, and the perioperative symptoms, signs and laboratory tests, such as monitoring of liver function, coagulation, and inflammation indexes were used to assess the Complications. Enhanced MRI or CT was routinely performed 1 month after surgery as the gold standard for ablation efficacy assessment. Subsequently, imaging and laboratory tests were performed every 2 to 3 months to regularly assess the occurrence of complications and tumor progression.\\u003c/p\\u003e\\n\\u003ch3\\u003eEvaluation indicators\\u003c/h3\\u003e\\n\\u003cp\\u003e1.Thermal ablation technical success rate (nodule-based technical assessment): the ratio of the number of nodules achieving ablation technical success to the total number of nodules. Technical success was defined as immediate post ablation ultrasonography of the liver tumor showing complete coverage of the original tumor area without acute complications.\\u003c/p\\u003e\\n\\u003cp\\u003e2.Postoperative complication rate: the ratio of the number of patients experiencing postoperative complications to the total number of patients.\\u003c/p\\u003e\\n\\u003cp\\u003e3.survival analysis\\u003c/p\\u003e\\n\\u003cp\\u003eSurvival curves were plotted using the KM (Kaplan-Meier) method with survival time in the horizontal coordinate and survival rate in the vertical coordinate.\\u003c/p\\u003e\\n\\u003cp\\u003eLocal tumor progression (LTP): defined as the appearance of new enhancing lesions within or at the margins of the completely ablated area of the tumor on enhanced CT or MRI examination 1 month after surgery. In this study, the rate of local tumor progression was calculated based on the number of nodules, i.e., the ratio of the number of nodules in which LTP occurred to the total number of nodules.\\u003c/p\\u003e\\n\\u003cp\\u003eTumor-free survival rate: the number of patients without recurrence or new tumors after treatment as a proportion of the total number of patients\\u003c/p\\u003e\\n\\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e\\n \\u003ch2\\u003estatistical analysis\\u003c/h2\\u003e\\n \\u003cp\\u003eThe collected data were entered into an electronic database and analyzed in strict accordance with statistical principles. Data were analyzed using SPSS statistical software, and measurements (e.g., tumor size) were expressed as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation if normally distributed, or median (range) if not normally distributed; count data (e.g., recurrence rate) were expressed as frequency and percentage.\\u003c/p\\u003e\\n\\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e\\u003ch2\\u003eBaseline information of patients\\u003c/h2\\u003e\\u003cp\\u003eA total of 281 patients were included in this study, with a median age of 58 years and a median length of hospitalization of 8 months; a total of 463 nodules, of which the median maximum tumor diameter of 16 mm.(Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). All patients included in the study successfully completed the surgery, and the success rate of patients' tumor ablation technique was 100% (463/463), and the effective rate of the technique was 100% (463/463). Radiofrequency ablation (RFA) was used in 36 (48.4%) patients, and radiofrequency ablation combined with microwave ablation (MWA) was used in 145 (51.6%) patients.\\u003c/p\\u003e\\u003c/div\\u003e\\n\\u003ch3\\u003ePostoperative complication rate\\u003c/h3\\u003e\\n\\u003cp\\u003eOf these 281 patients, 10 (3.6%) had postoperative complications including fever (n\\u0026thinsp;=\\u0026thinsp;4), abdominal infection with gastrointestinal bleeding (n\\u0026thinsp;=\\u0026thinsp;1), infection (n\\u0026thinsp;=\\u0026thinsp;2), infection with peritoneal effusion (n\\u0026thinsp;=\\u0026thinsp;1), infected fever (n\\u0026thinsp;=\\u0026thinsp;1), and subcutaneous hematoma (n\\u0026thinsp;=\\u0026thinsp;1), and there were no surgery-related deaths.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eFollow-up and survival outcomes\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e1. Overall survival\\u003c/p\\u003e\\u003cp\\u003eThe 281 patients included had a median follow-up of 5.97 months (range 0.40\\u0026ndash;21.60), and 1 patient died during follow-up, giving a survival rate of 99.6%.(Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003e2. Recurrence during follow-up\\u003c/p\\u003e\\u003cp\\u003eFour nodules out of 463 nodules during the follow-up period were diagnosed as LTP, with an incidence of LTP of 0.86% (4/463), and the four nodules were from four patients, two of whom were diagnosed as hepatocellular carcinoma and two of whom were diagnosed as liver metastases at the time of admission; at the time of treatment, one patient was treated with combined microwave ablation therapy, and the remaining three were treated only with radiofrequency ablation therapy, and all of them were treated with a single needle.\\u003c/p\\u003e\\u003cp\\u003eIntrahepatic recurrence occurred in 16.01% of 281 patients during follow-up (45/281), and the median tumor-free survival of the patients was 19.87 months, with a cumulative tumor-free survival rate of approximately 73.8% at one year.(Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e By retrospectively analyzing 281 patients with hepatocellular carcinoma treated with CT/MR-US fusion imaging-guided thermal ablation at our center, the results of this study demonstrated a high technical success rate (100%), low complication rate (3.6%), and low rate of intrahepatic recurrence (16.01%) in the treatment of hepatocellular carcinoma, as well as demonstrating good short-term survival outcomes (median follow-up 5.97 months, survival rate of 99.6%, cumulative LTP rate of 0.86%, and median tumor-free survival of 19.87 months). Technical success, cumulative LTP incidence, and intrahepatic recurrence rates turned out to be superior to the outcomes of other similar studies (100% vs. 83.8%-98.8%; 0.86% vs. 3.6%-11.9%; 16.52%-55.4%)(6\\u0026ndash;11).\\u003c/p\\u003e\\u003cp\\u003eUltrasound-guided thermal ablation is an important means of liver cancer treatment, which precisely applies thermal energy to tumor tissues through real-time ultrasound guidance, and uses high temperature to cause coagulative necrosis of tumor cells, so as to achieve minimally invasive eradication. However, there are certain limitations of traditional ultrasound guidance in percutaneous ablation, such as poor display of deep or small tumor boundaries and interference of gas artifacts. In recent years, the CT/MR-US fusion imaging technology has effectively compensated for the above shortcomings. This technology fuses enhanced CT or MRI images with real-time ultrasound images through a magnetic localization system, integrating the advantages of multimodal imaging and significantly improving the accuracy of tumor boundary identification. The tumor target area is pre-labeled based on CT/MR images and projected to the real-time ultrasound interface before ablation, which can accurately guide the implantation of ablation electrodes, avoiding puncture deviation and gas interference, and ensuring complete coverage of the tumor. For larger lesions, the single-needle multipoint overlapping ablation strategy can achieve tumor inactivation and reduce the risk of multi-needle operation. Single-needle ablation was used in 89.7% of the patients in this study, which not only reduces the medical cost, but also shortens the hospitalization time and reduces the physical and psychological burden of the patients.\\u003c/p\\u003e\\u003cp\\u003eIn this study, the incidence of major postoperative complications was only 3.6%, which was lower than the complication rate of conventional ultrasound-guided ablation (5%-10%)(3), and the CT/MR-US fusion imaging technology can display the ablation situation in real time, and once incomplete ablation is detected, supplemental ablation can be guided, which ensures that the ablation is complete in all the patients and reduces the risk of postoperative recurrence, and has a high value of application in the assessment of the efficacy of ultrasound-guided thermal ablation for patients with primary hepatocellular carcinoma.\\u003c/p\\u003e\\u003cp\\u003eDespite the short median follow-up time (5.97 months), the tumor-free survival rate in this study (73.8%) was generally consistent with previous reports (70%-80%)(4), suggesting that ultrasound fusion imaging may improve short-term prognosis. However, the intrahepatic recurrence rate (16.01%) was significantly higher than the LTP rate (0.86%). LTP is mostly associated with incomplete tumor ablation therapy, while intrahepatic recurrence may originate from micrometastases or new tumors, which can be detected by examining the HBV-DNA integration pattern, the type of mutation in the p53 gene, and the pattern of heterozygous chromosomal deletions; however, the reliability of these discriminatory methods has yet to be verified(12). Although thermal ablation can inactivate visible lesions, it has limited control of microvascular invasion or satellite lesions, and combined systemic therapy (e.g., targeted or immunotherapy) may be the future direction.\\u003c/p\\u003e\\u003cp\\u003eAlthough CT/MR-US/CEUS fusion imaging has significantly improved the accuracy of thermal ablation, there are still limitations in its clinical application. First, the technique is highly dependent on operator experience and requires systematic training to master core skills such as multimodal image alignment, real-time navigation, and error correction. Second, intraoperative dynamic interfering factors may affect the stability of the technique, such as changes in liver morphology due to artificial ascites intervention or surgical operation, and poor visualization of hepatic blood vessels, etc., which may lead to image alignment deviations and thus affect the judgment of ablation extent. Therefore, it is necessary to fully assess the anatomical characteristics of the patient before surgery, and combine with the dynamic calibration of enhanced images during surgery to avoid technical risks to the greatest extent possible.\\u003c/p\\u003e\\u003cp\\u003e This study has some limitations:(1) this is a retrospective study, which may lead to missing data or measurement bias; (2) the median follow-up time was only 5.97 months, which makes it difficult to assess the long-term efficacy; (3) The additional benefit of fusion imaging could not be quantified because no control group was set up for conventional ultrasound-guided ablation (4) the included cases were early-stage hepatocellular carcinomas (meeting the Milan criteria), and the conclusions may not be applicable to for patients with mid- to late-stage disease.\\u003c/p\\u003e\\u003cp\\u003eOverall, CT/MR-US fusion imaging is an effective technique for thermal ablation treatment of HCC and is suitable for the treatment of patients with HCC meeting the Milan criteria.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eCT/MR-US\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eCT/Magnetic Resonance-Ultrasound\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eHCC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eHepatocellular Carcinoma\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eOS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eOverall Survival\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eLTP\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eCumulative Local Tumor Progression\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eTPS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eTumor-Free Survival\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eWHO\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eWorld Health Organization\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eIARC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eInternational Agency for Research on Cancer\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eUS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eAlthough Ultrasound\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eKM\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eKaplan-Meier\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eRFA\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eRadiofrequency Ablation\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eMWA\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eMicrowave Ablation\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eLin Wang: Conceptualized and designed the study, conducted the imaging evaluation contributed to data analysis, and drafted the manuscript. Xuqi He: Performed data collection and contributed to manuscript revision. Kai Li: Conducted the imaging evaluation and provided critical insights into CT interpretation. Qingjing Zeng : Supervised the study, reviewed the manuscript critically for important intellectual content, and served as the corresponding author. All authors read and approved the final manuscript.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003eThank you to the team for their dedication to this research, thank you to the editors for their review, thank you!\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eData Availability Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and analyzed during the current study are not publicly available due to institutional data protection policies but are available from the corresponding author upon reasonable request and with the approval of the institutional ethics committee.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Review Board of The Third Affiliated Hospital of Sun Yat-sen University. Due to the retrospective nature of the study, the requirement for written informed consent was waived by the ethics committee. Patient confidentiality was strictly maintained throughout the study, and all data were anonymized before analysis.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n \\u003cli\\u003eWorld Health Organization. (2024, February 1). Global cancer burden growing, amidst mounting need for services. https://www.who.int/news/item/01-02-2024-global-cancer-burden-growing--amidst-mounting-need-for-services.\\u003c/li\\u003e\\n \\u003cli\\u003eMiao, W. G., Zhou, J. Y., \\u0026amp; Han, R. Q. (2024). Global epidemiological patterns of hepatocellular carcinoma: A comprehensive analysis [in Chinese]. Chinese Journal of Epidemiology (Zhonghua Liu Xing Bing Xue Za Zhi), 45(6), 865-869. https://doi.org/10.3760/cma.j.cn112338-20231027-00251\\u003c/li\\u003e\\n \\u003cli\\u003eLiang P, Yu J, Yu XL, Wang XH, Wei Q, Yu SY, Li HX, Sun HT, Zhang ZX, Liu HC, Cheng ZG, Han ZY. Percutaneous cooled-tip microwave ablation under ultrasound guidance for primary liver cancer: a multicentre analysis of 1363 treatment-naive lesions in 1007 patients in China. Gut. 2012 Jul;61(7):1100-1. doi: 10.1136/gutjnl-2011-300975. Epub 2011 Oct 13. PMID: 21997552.\\u003c/li\\u003e\\n \\u003cli\\u003eChen Z, Xie H, Hu M, Huang T, Hu Y, Sang N, Zhao Y. Recent progress in treatment of hepatocellular carcinoma. Am J Cancer Res. 2020 Sep 1;10(9):2993-3036. PMID: 33042631; PMCID: PMC7539784.\\u003c/li\\u003e\\n \\u003cli\\u003eXu E, Li K, Long Y, Luo L, Zeng Q, Tan L, He X, Huang Q, Wu Y, Zheng R. Intra-Procedural CT/MR-Ultrasound Fusion Imaging Helps to Improve Outcomes of Thermal Ablation for Hepatocellular Carcinoma: Results\\u0026nbsp;in 502 Nodules. Ultraschall Med. 2021 Apr;42(2):e9-e19. English. doi: 10.1055/a-1021-1616. Epub 2019 Oct 31. PMID: 31671457.\\u003c/li\\u003e\\n \\u003cli\\u003eXu ZF, Xie XY, Kuang M, Liu GJ, Chen LD, Zheng YL, Lu MD. Percutaneous radiofrequency ablation of malignant liver tumors with ultrasound and CT fusion imaging guidance. J Clin Ultrasound. 2014 Jul-Aug;42(6):321-30. doi: 10.1002/jcu.22141. Epub 2014 Feb 25. PMID: 24615771.\\u003c/li\\u003e\\n \\u003cli\\u003eAhn SJ, Lee JM, Lee DH, Lee SM, Yoon JH, Kim YJ, Lee JH, Yu SJ, Han JK. Real-time US-CT/MR fusion imaging for percutaneous radiofrequency ablation of hepatocellular carcinoma. J Hepatol. 2017 Feb;66(2):347-354. doi: 10.1016/j.jhep.2016.09.003. Epub 2016 Sep 17. PMID: 27650284.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eSong KD, Lee MW, Rhim H, Kang TW, Cha DI, Sinn DH, Lim HK. Percutaneous US/MRI Fusion-guided Radiofrequency Ablation for Recurrent Subcentimeter Hepatocellular Carcinoma: Technical Feasibility and Therapeutic Outcomes. Radiology. 2018 Sep;288(3):878-886. doi: 10.1148/radiol.2018172743. Epub 2018 Jun 19. PMID: 29916771.\\u003c/li\\u003e\\n \\u003cli\\u003eHuang J, Yan L, Cheng Z, Wu H, Du L, Wang J, Xu Y, Zeng Y. A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria. Ann Surg. 2010 Dec;252(6):903-12. doi: 10.1097/SLA.0b013e3181efc656. PMID: 21107100.\\u003c/li\\u003e\\n \\u003cli\\u003eYu J, Yu XL, Han ZY, Cheng ZG, Liu FY, Zhai HY, Mu MJ, Liu YM, Liang P. Percutaneous cooled-probe microwave versus radiofrequency ablation in early-stage hepatocellular carcinoma: a phase III randomised controlled trial. Gut. 2017 Jun;66(6):1172-1173. doi: 10.1136/gutjnl-2016-312629. Epub 2016 Nov 24. PMID: 27884919; PMCID: PMC5532455.\\u003c/li\\u003e\\n \\u003cli\\u003eShiina S, Tateishi R, Arano T, Uchino K, Enooku K, Nakagawa H, Asaoka Y, Sato T, Masuzaki R, Kondo Y, Goto T, Yoshida H, Omata M, Koike K. Radiofrequency ablation for hepatocellular carcinoma: 10-year outcome and prognostic factors. Am J Gastroenterol. 2012 Apr;107(4):569-77; quiz 578. doi: 10.1038/ajg.2011.425. Epub 2011 Dec 13. PMID: 22158026; PMCID: PMC3321437.\\u0026nbsp;\\u003c/li\\u003e\\n \\u003cli\\u003eXia, Y., Yang, T., \\u0026amp; Wang, K. (2021). Chinese expert consensus on prevention and treatment of postoperative recurrence in hepatocellular carcinoma after hepatectomy (2020 edition) [in Chinese]. Chinese Journal of Practical Surgery (Zhongguo Shiyong Waike Zazhi), 41(1), 20-30. https://doi.org/10.19538/j.cjps.issn1005-2208.2021.01.03\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTable 1: Baseline profile of patients\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eBaseline\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003eResults\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eNumber of patients (n)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e281\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eSex (male/female) [n (%)]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e231（82.2%）/50（17.8%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e58（19-84）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eCirrhosis (no/yes)[n (%)]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e93（33.1%）/188（66.9%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eAFP(ng/mL)（＜20/20-200/＞200）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e215（77.6%）/39（14.1%）/23（8.3%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eDiagnosis (hepatocellular carcinoma/hepatic metastases/other)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e238（84.7%）/27（9.6%）/16（5.7%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eComorbidity (none/yes)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e156（55.5%）/124（44.1%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eAblation technique (RFA/RFA+MWA) [n (%)]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e136（48.4%）/145（51.6%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eNumber of needles (single/double)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e252（89.7%）/29（10.3%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eNumber of nodules (pcs)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e463\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eLength of hospitalization (months)\\u003c/p\\u003e\\n \\u003cp\\u003eMedian (range)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e8（2-43）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003eMaximum tumor diameter (mm)\\u003c/p\\u003e\\n \\u003cp\\u003eMedian (range)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e16（4-57）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 306px;\\\"\\u003e\\n \\u003cp\\u003ePostoperative complications (none/yes)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 262px;\\\"\\u003e\\n \\u003cp\\u003e271（96.4%）/10（3.6%）\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Radiofrequency Ablation, Liver Neoplasms, CT/MR-US Fusion Imaging\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-6909462/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-6909462/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eObjective\\u003c/h2\\u003e\\u003cp\\u003eTo investigate the efficacy and safety of intraoperative CT/magnetic resonance-ultrasound (CT/MR-US) fusion imaging in thermal ablation therapy for hepatocellular carcinoma (HCC).\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e\\u003cp\\u003eA total of 281 HCC patients (231 males and 50 females, median age 58 years) meeting the Milan criteria were retrospectively enrolled from January 2023 to December 2024. All patients underwent percutaneous thermal ablation guided by intraoperative CT/MR-US fusion imaging. Technical efficacy and major complications were calculated. Overall survival (OS), cumulative local tumor progression (LTP), and tumor-free survival(TFS) were estimated using the Kaplan-Meier method.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003eAmong 463 nodules in 281 patients, all procedures were successfully completed. The technical and clinical success rates were both 100% (463/463). The postoperative complication rate was 3.6% (10/281). During a median follow-up of 5.97 months, the OS rate was 99.6%, with an LTP rate of 0.86% (4/463) and an intrahepatic recurrence rate of 16.01% (45/281). The median TFS was 19.87 months.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e\\u003cp\\u003eCT/MR-US fusion imaging is an effective technique for HCC thermal ablation, demonstrating high success rates, low complications, and favorable short-term outcomes. It is particularly applicable for HCC patients meeting the Milan criteria. Further validation is required for its long-term efficacy and applicability in advanced-stage HCC.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Evaluation of the efficacy of CT/MR-Ultrasound Fusion Imaging in Ablation of Hepatocellular Carcinoma\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-30 10:23:11\",\"doi\":\"10.21203/rs.3.rs-6909462/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-02-05T14:19:30+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-13T21:05:41+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-05T06:33:18+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"59449116884649567957090591633131233197\",\"date\":\"2026-01-04T12:02:07+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"189025915080824484470794944138544842272\",\"date\":\"2026-01-03T09:47:47+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"6611203353573454191506406511072099787\",\"date\":\"2025-12-28T12:50:38+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-09-19T04:25:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-09-16T12:10:11+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-06-19T23:03:38+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-06-18T09:57:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Scientific Reports\",\"date\":\"2025-06-17T02:21:51+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"5981d8d9-9a7d-4482-be2c-26aeae3319f2\",\"owner\":[],\"postedDate\":\"September 30th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"in-revision\",\"subjectAreas\":[{\"id\":55534268,\"name\":\"Biological sciences/Cancer\"},{\"id\":55534269,\"name\":\"Health sciences/Medical research/Outcomes research\"}],\"tags\":[],\"updatedAt\":\"2026-02-05T14:24:37+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-30 10:23:11\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-6909462\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-6909462\",\"identity\":\"rs-6909462\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}