In Liver Cancer Surveillance, Traditional Methods Meet Emerging Strategies
US remains the standard, but alternative approaches are gaining momentum
In concert with the RadioGraphics monograph, RSNA News shares the latest on the role of medical imaging in disease screening.
A risk-stratified approach to US-based hepatocellular carcinoma (HCC) surveillance, with surveillance intensity aligned with individualized risk, improves outcomes while optimizing cost-effectiveness, according to a leading expert in liver imaging.
The biggest risk factor for HCC is chronic liver disease, with over 80% of cases occurring in patients with cirrhosis. Historically, viral hepatitis infections have been the leading cause of cirrhosis, but recent improvements in treatments have led to a drop in hepatitis-related disease.
Concurrently, non-viral causes like fatty liver disease are rising quickly and are a major reason why HCC rates in the U.S. have tripled over the past four decades, according to the American Cancer Society.
“The obesity epidemic has become a major risk factor for the development of liver disease,” said Victoria Chernyak, MD, MS, professor of radiology at Columbia University Irving Medical Center in New York City. “What used to be a minor cause of cirrhosis is now rapidly increasing worldwide to become one of the leading causes of cirrhosis in high-income countries.”
In a recent article in RadioGraphics, Dr. Chernyak and colleagues highlight how surveillance strategies are evolving as HCC risk factors and patient populations continue to change.
Early detection remains central to those efforts because curative treatment options for HCC, including resection and transplantation, are limited to early-stage disease.
For most patients at high risk of HCC, the standard surveillance strategy combines US examinations and serum alpha-fetoprotein (AFP) level testing every six months.
US alone detects 47% of early-stage HCC cases. When AFP is added, sensitivity increases to 63%, comparable to the 62% sensitivity reported for CT.
LI-RADS US-1 (negative) category in a 66-year-old woman with hepatitis C virus cirrhosis. Sagittal and transverse surveillance US images show a calcified granuloma (arrows) and no other observations. The patient recommendation was to continue the routine surveillance schedule.
https://doi.org/10.1148/rg.260010 ©RSNA 2026
Scoring System Guides Follow-Up Care
To help standardize interpretation and guide follow-up recommendations, US findings are categorized using Liver Imaging Reporting and Data System (LI-RADS) Surveillance algorithm. Imaging results are expressed in LI-RADS Ultrasound Category and Visualization Scores.
The Category Score includes US-1 (negative) indicating no evidence for HCC, US-2 (subthreshold) indicating a lesion less than 10 mm, not definitely benign, and US-3 (positive) indicating a finding of greater than 10 millimeters that was not previously characterized as benign.
The Visualization Score conveys the expected sensitivity of the test and is informed by the ability to adequately assess the entirety of the liver parenchyma. Three Visualization scores are possible: VIS-A which means no or minor limitations; VIS-B which connotes acceptable quality with some limitations; and VIS-C meaning major limitations to the image quality. Together, the scores determine patient management.
“If a patient has US-1 and VIS-A scores, meaning we’re not seeing anything concerning and it’s a very high-quality ultrasound. We can be confident in telling them that it is safe to come back in six months,” Dr. Chernyak said. “But it may not be prudent to wait six months for a follow-up exam in a patient who has US-1 with a poor-quality ultrasound.”
Repeat examinations often boost the Visualization Score. Research has shown that more than 50% of patients with a VIS-C score on their initial examination may improve to a VIS-A or VIS-B on a follow-up US. However, research has shown that a patient with a VIS-C score at a repeat examination is unlikely to improve in the future.
“That’s why, if we’re unable to get a better quality on a repeat examination, we’ll switch to alternative surveillance methods like CT or MRI,” Dr. Chernyak said.
“Mounting evidence suggests that varying surveillance strategies to incorporate serum biomarker levels and alternative imaging modalities may be more effective when applied to appropriately risk-stratified cohorts.”
— VICTORIA CHERNYAK, MD, MS
Alternative Imaging Expands Surveillance Options
These alternative methods can help overcome US’s suboptimal sensitivity in certain high-risk subgroups such as patients with obesity, hepatic steatosis or advanced cirrhosis. In such patients, alternative strategies like abbreviated MRI (aMRI) demonstrate higher sensitivity for HCC.
Protocols like noncontrast aMRI, dynamic aMRI and hepatobiliary phase aMRI combine selected sequences to maximize detection of suspicious lesions while excluding benign entities like cysts and hemangiomas. Examinations can be as short as six minutes, compared with approximately 40 minutes for a complete MRI examination and 30 minutes for a US study.
“In essence, you’re creating a very focused exam that is tailored to answering the question, ‘Is there a lesion of concern?’” Dr. Chernyak said. “There are some implementation issues, including insurance coverage, but abbreviated MRI is probably going to be used more often as the number of patients with cirrhosis who need screening increases.”
Dr. Chernyak noted that as with any cancer surveillance program, the effectiveness of the different approaches must be balanced against the costs in time, money and resources. “Abbreviated MRI may have the highest sensitivity for HCC detection, but its availability is limited, while the more widely available blood tests are less sensitive,” she said. “Emerging strategies like blood-based biomarkers, liquid biopsy and AI augmentation offer great promise but their clinical impact is uncertain.”
Ultimately, surveillance efficiency comes down to factors like individual HCC risk, imaging costs, surveillance use and societal willingness-to-pay thresholds, along with what works best for the patient. This reality supports a departure from uniform “one-size-fits-all” strategies in favor of personalized, risk-adapted surveillance paradigms, Dr. Chernyak said.
“The currently endorsed strategy for surveillance with semiannual ultrasound and serum AFP level testing has been shown to be cost-effective and to improve survival,” she said. “However, mounting evidence suggests that varying surveillance strategies to incorporate serum biomarker levels and alternative imaging modalities may be more effective when applied to appropriately risk-stratified cohorts.”
For More Information
Access the RadioGraphics article, “Surveillance for Hepatocellular Carcinoma in Patients at High Risk.”
Read previous RSNA News stories on liver imaging: