Original Article

Acta Radiologica
2023, Vol. 64(9) 2506–2517
Fusion imaging versus ultrasound-guided © The Foundation Acta Radiologica
2023
percutaneous thermal ablation of liver Article reuse guidelines:
sagepub.com/journals-permissions
cancer: a meta-analysis DOI: 10.1177/02841851231187638
journals.sagepub.com/home/acr

Yangang Sheng1, Xueke Sun2, Hongmei Sun3, Jinyan Qi4, Hua Li5,
Jiankui Luan2and Deyin Zhai5

Abstract
Background: Ultrasound-guided percutaneous thermal ablation has become an alternative treatment for small hepato-
cellular carcinoma (HCC). Recent evidence suggests that fusion imaging (FI) may improve the feasibility and efficacy of
thermal ablation for HCC, while the clinical evidence remains limited.
Purpose: To compare FI versus ultrasound-guided thermal ablation for HCC.
Material and Methods: Relevant cohort or randomized controlled trials were found by searching Medline, Web of
Science, Cochrane Library, and Embase. The pooling of results was performed using a random-effects model incorpor-
ating heterogeneity.
Results: In this meta-analysis, 15 studies involving 1472 patients (1831 tumors) for FI-guided ablation and 1380 patients
(1864 tumors) for ultrasound-guided ablation were included. Pooled results showed that compared to conventional HCC
ablation guided by ultrasound, the FI-guided procedure showed a similar technique efficacy rate (risk ratio [RR] = 1.01,
95% confidence interval [CI] = 1.00–1.02, P = 0.25; I2 = 30%). However, FI-guided tumor ablation was associated with a
lower incidence of overall complications (RR = 0.70, 95% CI = 0.50–0.97, P = 0.03; I2 = 0%). Moreover, patients receiving
FI-guided tumor ablation had a lower risk of local tumor progression during follow-up than those with ultrasound-guided
ablation (RR = 0.61, 95% CI = 0.47–0.78, P < 0.001; I2 = 13%). Subgroup analysis according to FI strategy, imaging tech-
niques in controls, and tumor diameter showed consistent results (p for subgroup difference all >0.05).
Conclusion: FI-guided thermal ablation may be more effective and safer than ultrasound-guided ablation for patients
with HCC.

Keywords
Liver neoplasms, radio frequency ablation, multimodal imaging, ultrasonography, meta-Analysis
Date received: 1 June 2023; accepted: 24 June 2023

Introduction 1
Department of Ultrasound, Laizhou People’s Hospital, Laizhou City, PR
For early hepatocellular carcinomas (HCC), percutaneous China
2
Department of Medical Imaging, Laizhou People’s Hospital, Laizhou City,
thermal ablation is widely accepted as an effective and PR China
mini-invasive treatment (1). Technically, percutaneous 3
Department of Nursing, Laizhou People’s Hospital, Laizhou City, PR
thermal ablation includes radiofrequency ablation (RFA) China
4
and microwave ablation (MWA) (2). For HCC with dia- Department of Ear-nose-throat, Laizhou People’s Hospital, Laizhou City,
meters <3 cm, percutaneous thermal ablation has been PR China
5
Department of Internal Medicine, Laizhou People’s Hospital, Laizhou
shown to confer similar therapeutic efficacy to surgical City, PR China
resection (3,4). During the procedure of percutaneous
thermal ablation for HCC, ultrasound is the conventionally Yangang Sheng, Xueke Sun and Hongmei Sun contributed equally to this
preferred real-time imaging modality to guide the needling work and share first authorship.
position, track tumor lesions during hepatic, respiratory
Corresponding author:
movement, and avoid the injury of vital organs (5). Deyin Zhai, Department of Internal Medicine, Laizhou People’s Hospital,
Moreover, optimized ultrasound guidance is necessary to 1718 Wuli Street, Laizhou City, PR China.
confirm the immediate efficacy of the treatment and reduce Email: zhaideyinlz@163.com
Sheng et al.
the incidence of local tumor progression (LTP) during
follow-up (6,7). However, not all HCC lesions were with
adequate visibility on conventional ultrasound, such as
those with small size (diameter <2 cm), with the isoechoic
feature, or in difficult locations within the body (8,9).
Although contrast-enhanced ultrasound (CEUS) has been
suggested to overcome some shortcomings of conven-
tional ultrasound in guiding the ablation of HCC for
tumors with inadequate blood supply, the application of
CEUS was restricted (10).
With the development of digital and three-dimensional
(3D) imaging techniques in recent years, fusion imaging
(FI) has emerged as a more accurate and efficient tool to
support mini-invasive procedures, including percutaneous
ablation for HCC lesions (11,12). By combining real-time
ultrasound or CEUS images with high-resolution images,
such as computed tomography (CT), magnetic resonance
imaging (MRI), or 3D ultrasound (3DUS), FI has been sug-
gested to confer more efficiencies than conventional ultra-
sound in visualizing the target lesion, determining the
ablation edge, and evaluating the therapeutic efficacy of per-
cutaneous ablation for HCC (13–15). However, the clinical
evidence of the potential superiority of FI-guided thermal
ablation to ultrasound-guided ablation remains limited. A
few head-to-head comparative studies have been performed.
However, these studies have limited sample sizes, and a
summarized study with meta-analysis is needed (16–30).
Accordingly, we performed a systematic review and
meta-analysis in this study to compare the efficacy and
safety of FI versus ultrasound-guided thermal ablation
for HCC.
Material and Methods
This study adhered to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA 2020) guide-
line (31,32) and the Cochrane Handbook for Systematic Reviews
and Meta-analyses (Handbook for Systematic Reviews and
Meta-analysis) (33). Approval from the Institutional Review
Board was not required as this is a meta-analysis.
Literature search
We obtained studies by searching several databases including
Medline, Web of Science, Cochrane Library, and Embase
with a combined keyword strategy: (i) “hepatocellular” OR
“liver” OR “hepatic”; (ii) “carcinoma” OR “cancer” OR
“tumor” OR “malignancy” OR “malignant” OR “neoplasm”;
(iii) “ablation” OR “radiofrequency” OR “thermal ablation”
OR “microwave ablation” OR “RFA”; and (iv) “fusion” OR
“fusion imaging.” The included studies were published in
English and involved human particiants. To complement
this process, we hand-screened the citations of the related ori-
ginal and review articles. Literature searches were last con-
ducted on 30 December 2022.
2507
Selection of studies
The PICOS criteria were used for study inclusion.
P (patients): patients with a confirmed diagnosis of HCC
who were planned to receive percutaneous thermal ablation;
I (intervention or exposure): ablation guided by FI,
including CT/MRI or 3DUS fusion with ultrasound;
C (control): ablation guided by conventional ultrasound
or CEUS;
O (outcomes): reported at least one of the following out-
comes, which included the technique efficacy rate (TER),
incidence of complications, and risk of LTP during
follow-up. This study defined technique effectiveness as
the complete destruction of the macroscopic tumor as deter-
mined by imaging immediately after the procedure (4).
Complications were defined according to the criteria of
the original studies. In addition, LTP was defined as an
incompletely treated tumor that continues to grow or a
new tumor (or satellite tumors) that grows at the original
site (34).
S (study design): cohort studies or randomized con-
trolled trials (RCTs) published as full-length articles in
peer-reviewed journals.
The following studies were excluded: preclinical studies;
review articles; editorials; meta-analyses; studies that did
not include patients with HCC; studies without an interven-
tion of FI-guided thermal ablation; studies without a control
ultrasound-guided ablation; and studies that did not report
any of the above outcomes. Studies with the largest
sample sizes were included in the meta-analysis if multiple
studies with overlapped patients were retrieved.
Data collection and study quality assessment
Two independent authors searched, collected, and assessed
the data. Discussions with the corresponding author were
used to resolve disagreements. The data collected were as
follows: (i) author, year, location, and study design; (ii) par-
ticipant characteristics, such as diagnosis, patient number,
tumor number, mean age, sex, and mean diameters of the
tumors; (iii) details of intervention and control procedures;
(iv) variables adjusted or matched between groups; and (v)
follow-up durations and outcomes reported. An assessment
of study quality was conducted according to the
Newcastle-Ottawa Scale (NOS) (35). Based on this scale,
each study was rated using three broad criteria: selection
of the study groups; the comparability of the groups; and
the ascertainment of the outcome of interest. The total
score was in the range of 1–9, and a higher score indicated
better study quality. The Cochrane Risk of Bias Tool was
used to determine the quality of the included RCTs (33)
according to the following aspects: assigning random
sequences; concealing allocations; blinding participants
and personnel; blinding outcomes assessors; incomplete
outcomes data; and selective outcome reporting.
Table 1. Characteristics of the included studies.
2508

No. of No. of
patients/ patients/ Mean Mean tumor Follow-up
tumor in FI tumor in age Men diameter Control duration Outcomes
Study Country Design group control group (years) (%) (mm) Procedure FI protocol protocol (months) Characteristics matched reported
Minami, Japan RC 123/155 192/344 70.2 72.7 14.6 RFA CT/MRI-US CEUS 43.2 Age, sex, CPS, tumor size and TER, LTP, and
2014 location complication
Toshikuni, Japan PC 25/25 20/20 73.3 48.9 19 RFA CT/MRI-US US 27 Age, sex, etiology, CPS, tumor size, TER and LTP
2017 location, combined with TACE
Ma, 2019 China RC 97/110 83/90 52.2 88.9 19 RFA or CT/ US 66 Age, sex, etiology, CPS, tumor size, TER, LTP, and
MWA MRI-CEUS location, combined with TACE complications
Huang, China RCT 124/153 62/75 53.1 90.3 18.9 RFA or CT/ CEUS 24 Age, sex, etiology, CPS, tumor size, TER, LTP, and
2019a MWA MRI-CEUS location, ablation methods, and complications
associated with other procedures
Huang, China RCT 125/153 63/75 54.6 89.9 18.5 RFA or 3DUS-CEUS CEUS 24 Age, sex, etiology, CPS, tumor size, TER, LTP, and
2019b MWA location, ablation methods, and complications
associated with other procedures
Ju, 2019 China PC 114/146 93/122 63.7 84.1 20.1 RFA or CT/ CEUS 44 Age, sex, etiology, CPS, number of TER, LTP, and
MWA MRI-CEUS lesions, tumor size, location, complications
ablation methods, and associated
with other procedures
Zhang, China RC 19/19 24/24 60.9 72.1 41 MWA 3DCT-US US 10 Age, sex, etiology, and tumor size TER, LTP, and
2019 complications
Long, 2020 China RC 328/511 174/294 52 87.8 16 RFA or CT/ US 30 Age, sex, etiology, CPS, size and no. TER, LTP, and
MWA MRI-CEUS of tumors complications
Hirooka, Japan RC 80/80 71/71 70.5 80.1 19.6 RFA 3DUS-US US NR Age, sex, etiology, CPS, tumor size LTP
2020 and location
Minami, Japan RC 101/121 325/453 70.2 71.1 17.2 RFA 3DUS-US US 19 Age, sex, etiology, CPS, AFP, tumor TER, LTP, and
2020 size and location, and combination complications
with TACE
Schullian, Austria RC 14/29 14/33 65 78.6 29.5 RFA MRI-US US 10 Age, sex, etiology, tumor size and TER, LTP, and
2020 location, and previous treatment complications
Wang, China RC 51/51 64/64 69.5 78.3 15.9 RFA EOB-MRI-US CEUS 12.6 Age, sex, etiology, AFP, tumor size TER and LTP
2020 and location
You, 2021 China RC 14/14 13/13 54 92.6 21.1 RFA MRI-US US 22.5 Age, sex, etiology, CPS, AFP, tumor TER, LTP, and
size and location complications
Gu, 2021 China PC 46/46 52/52 57.6 46.9 23.6 RFA CT/ CEUS 8.5 Age, sex, CPS, and tumor size TER, LTP, and
MRI-CEUS complications
Zhang, China RC 26/28 8/8 55.1 82.4 18.6 RFA or CT/ CEUS 19.5 Age, sex, etiology, CPS, AFP, and TER and LTP
2021 MWA MRI-CEUS tumor location

(continued)
Acta Radiologica 64(9)
 Sheng et al.

Table 1. (continued).

No. of No. of
patients/ patients/ Mean Mean tumor Follow-up
tumor in FI tumor in age Men diameter Control duration Outcomes
Study Country Design group control group (years) (%) (mm) Procedure FI protocol protocol (months) Characteristics matched reported
Liu, 2022 China RC 185/190 122/126 55.5 88.6 20.2 RFA or CT/MRI-US US 12.5 Age, sex, etiology, CPS, AFP, tumor TER, LTP, and
MWA size and location, and combination complications
with TACE

3DUS, three-dimension ultrasound; AFP, alpha-fetoprotein; CEUS, contrast-enhanced ultrasound; CPS, Child-Pugh score; CT, computed tomography; FI, fusion imaging; LTP, local tumor progression; MRI,
magnetic resonance imaging; MWA, microwave ablation; PC, prospective cohort; RC, retrospective cohort; RCT, randomized controlled trial; RFA, radiofrequency ablation; TACE, transcatheter arterial
chemoembolization; TER, technology efficacy rate; US, ultrasound.
2509
2510
Statistical methods
In the present study, the outcome of categorized variables
was presented as risk ratio (RR) and 95% confidence inter-
val (CI) (36). An evaluation of the extent of heterogeneity
between studies was conducted by performing Cochrane’s
Q test and estimating the I2 statistic, as explained previously
(36,37). An I2 > 50% indicates heterogeneity. The results
were pooled using a random-effects model that considered
possible between-study heterogeneity (33). For studies
including multiple intervention groups of different strat-
egies for FI (e.g. CT/MRI-US and 3DUS-US), the control
groups with ultrasound-guided ablation were equally split
and included as independent comparisons to overcome a
unit-of-analysis error, according to the instruction of
Cochrane’s Handbook (33). Whenever possible, predefined
subgroup analyses were performed according to the differ-
ent strategies for FI, ultrasound techniques in control (ultra-
sound or CEUS), and mean diameters of the tumors. A
median of the continuous variable was selected as a
cutoff for defining subgroups. To determine whether publi-
cation bias exists, funnel plots were constructed and visu-
ally examined for symmetry (38). In addition, for the
purpose of testing for publication bias, Egger’s regression
analysis was conducted (38). RevMan (version 5.1;
Cochrane Collaboration, Oxford, UK) and Stata were
used for the statistical analysis. P < 0.05 indicates statistical
significance.
Results
Study retrieval
As shown in Fig. 1, after a search of electronic databases,
675 articles were retrieved, and 544 remained after duplica-
tions were removed. Among the 544 titles and abstracts
screened for the meta-analysis, 491 were excluded due to
their non-compliance with the criteria of the meta-analysis.
Of the remaining 53 studies, 38 were subsequently
excluded due to the reasons listed in Fig. 1 after full texts
were read by two authors independently. As a result, 15
studies were enrolled in the meta-analysis (16–30).
Study characteristics
Table 1 summarizes the characteristics of the studies
included in the meta-analysis. Overall, one RCT (18),
three prospective cohort studies (17,19,27), and 11 retro-
spective cohort studies (16,20–26,28–30) were available.
Since one study included two comparisons of different FI
techniques with ultrasound (CT/MR-CEUS vs. CEUS and
3DUS-CEUS vs. CEUS) (18), these datasets were included
independently in the meta-analysis. Accordingly, 16 com-
parisons (datasets) were available for this meta-analysis,
involving 1472 patients (1831 tumors) for FI-guided
Acta Radiologica 64(9)
ablation and 1380 patients (1864 tumors) for ultrasound-
guided ablation. These studies were published between
2014 and 2022, and were performed in Japan, China, and
Austria. All the studies included patients with HCC who
were allocated to an intervention group of patients with
FI-guided percutaneous thermal ablation and a control
group of patients with ultrasound (conventional ultrasound
or CEUS) guided ablation. The number of included patients
was in the range of 28–839 in the included studies. The
mean age of the included patients was in the range of 52–
73 years. The mean diameter of the tumors was in the
range of 14–41 mm. As for the ablation procedures, RFA
was used in eight studies (16,17,22,24–28), MWA was
used in one study (21), and RFA or MWA was used in
the remaining six studies (18–20,23,29,30). The median
follow-up durations were 8–66 months, and variables
such as age, sex, Child-Pugh Score, etiology, tumor size,
location, and so on were matched between patients with
FI and ultrasound-guided ablation. For the cohort studies
(16,17,19–30), the included studies received a NOS of 7–
9 stars, which indicates good study quality (Table 2). For
the RCT (18), the details of random sequence generation
were reported, but not for the details of allocation conceal-
ment. The study was blinded to the outcome assessment but
to the patient.
Meta-analysis results
Pooled results of 15 comparisons from 14 studies (16–
21,23–30) indicated that compared to conventional HCC
ablation guided by ultrasound, FI-guided procedure
showed similar TER (RR = 1.01, 95% CI = 1.00–1.02, P
= 0.25) (Fig. 2a) with mild heterogeneity (p for
Cochrane’s Q test = 0.13, I2 = 30%). Sensitivity analyses
by excluding one dataset at a time showed consistent
results (RR = 1.00 or 1.01, P all >0.05). However, evidence
from 12 studies (16,18–25,27,28,30) showed that FI-guided
tumor ablation was associated with a lower incidence of
overall complications (RR = 0.70, 95% CI = 0.50–0.97,
P = 0.03) (Fig. 2b) with no significant heterogeneity
(p for Cochrane’s Q test = 0.62, I2 = 0%). Similarly, omit-
ting one dataset also did not significantly change the
results (RR = 0.65–0.77, P all <0.05). Moreover, a
meta-analysis with 14 studies suggested that patients
receiving FI-guided tumor ablation had a lower risk of
LTR during follow-up compared to those with ultrasound-
guided ablation (RR = 0.61, 95% CI = 0.47–0.78, P <
0.001) (Fig. 2c) with mild heterogeneity (p = 0.31, I2 =
13%). The results were consistent for sensitivity analysis
by excluding one dataset sequentially (RR = 0.56–0.66, P
all <0.05). Subgroup analysis according to the difference
of FI strategy, imaging techniques in controls, and tumor
diameter showed consistent results for the meta-analyses
of TER, the incidence of complications, and the risk of
Sheng et al.
Fig. 1. Diagram illustrating the process of searching databases and identifying studies.
LTP during follow-up (P for subgroup difference all >0.05)
(Table 3).
Publication bias
The funnel plots for the meta-analyses of TER, the inci-
dence of complications, and the risk of LTP during
follow-up are shown in Figs. 3a–c. There are low publica-
tion bias risks based on the plots’ symmetry for these
meta-analyses. Moreover, Egger’s regression tests did not
reveal any significant publication bias (P values all >0.10).
Discussion
In this systematic review and meta-analysis, we pooled the
results of 15 available studies, and the results showed that
compared to percutaneous thermal ablation guided with
ultrasound or CEUS, FI-guided thermal ablation for HCC
2511
had a similar TER. However, FI-guided thermal ablation
was associated with a lower incidence of complications
and a reduced risk of LTP in patients with HCC during
follow-up. The results were further validated in sensitivity
analyses by excluding one study at a time and in subgroup
analyses according to the different strategies in FI, control
images, and mean diameter of the tumors. Taken together,
although large-scale RCTs are needed to validate these find-
ings, the results of the meta-analysis indicate that guided
thermal ablation may be more effective and safer than
ultrasound-guided ablation for patients with HCC.
To the best of our knowledge, only one previous
meta-analysis evaluated the possible role of FI-guided
RFA for patients with HCC (39). This meta-analysis
included only six relevant studies published before April
2021, with a total of 1168 patients with HCC. Although
this study showed a similar TER for FI and ultrasound-
guided thermal ablation for HCC, it failed to indicate a
 2512

Table 2. Quality evaluation of the included cohort studies.

Was
Demonstration that follow-up
Selection outcome of interest long enough Adequacy of
Representativeness of the Ascertainment was not present at Comparability: Comparability: Assessment for outcomes follow-up of
Study of the patients controls of intervention start of study age and sex other factors of outcome to occur? cohorts Total

Minami, 0 1 1 1 1 1 1 1 1 8
2014
Toshikuni, 1 1 1 1 1 1 1 1 1 9
2017
Ma, 2019 0 1 1 1 1 1 1 1 1 8
Ju, 2019 1 1 1 1 1 1 1 1 1 9
Zhang, 0 1 1 1 1 1 1 0 1 7
2019
Long, 2020 0 1 1 1 1 1 1 1 1 8
Hirooka, 0 1 1 1 1 1 1 0 1 7
2020
Minami, 0 1 1 1 1 1 1 1 1 8
2020
Schullian, 0 1 1 1 1 1 1 0 1 7
2020
Wang, 0 1 1 1 1 1 1 1 1 8
2020
You, 2021 0 1 1 1 1 1 1 1 1 8
Gu, 2021 1 1 1 1 1 1 1 0 1 8
Zhang, 0 1 1 1 1 1 1 1 1 8
2021
Liu, 2022 0 1 1 1 1 1 1 1 1 8
Acta Radiologica 64(9)
Sheng et al. 2513

Fig. 2. Forest plots comparing the feasibility, safety, and efficacy of FI versus ultrasound-guided percutaneous thermal ablation for
HCC: (a) forest plots for the meta-analysis of TER; (b) forest plots for the meta-analysis of the incidence of complications; and (c) forest
plots for the meta-analysis of the risk of LTP during the patients’ follow-up. FI, fusion imaging; HCC, hepatocellular carcinoma; LTP, local
tumor progression; TER, technique efficacy rate.

superiority of FI-guided ablation to ultrasound-guided abla- electronic databases, which retrieved 15 up-to-date, rele-
tion (16–30). Compared to this previous meta-analysis, our vant studies. The overall sample size of this meta-analysis
study has several strengths in methodology. First, an exten- is much larger than the previous one (2852 vs. 1168),
sive literature search was performed in four commonly used which may be adequate to achieve significant results for
2514 Acta Radiologica 64(9)

Table 3. Subgroup analysis.

Study characteristics No. of datasets RR (95% CI) I2 (%) P for subgroup effect P for subgroup difference

TER
FI strategy
CT/MRI 13 1.00 (0.99–1.01) 14 0.64
3DUS 2 1.02 (0.98–1.05) 75 0.37 0.47
Control imaging
US 8 1.01 (0.99–1.02) 28 0.40
CEUS 7 1.01 (0.99–1.03) 35 0.40 0.80
Mean tumor diameter (mm)
<19 7 1.00 (0.99–1.01) 14 0.78
≥19 8 1.02 (0.99–1.04) 41 0.18 0.26
Complications
FI strategy
CT/MRI 10 0.72 (0.48–1.07) 6 0.10
3DUS 3 0.61 (0.28–1.34) 0 0.22 0.72
Control imaging
US 8 0.65 (0.33–1.31) 26 0.23
CEUS 5 0.74 (0.49–1.11) 0 0.14 0.77
Mean tumor diameter (mm)
<19 5 0.75 (0.45–1.23) 0 0.25
≥19 8 0.67 (0.43–1.03) 0 0.07 0.74
LTP
FI strategy
CT/MRI 13 0.65 (0.50–0.84) 8 <0.001
3DUS 2 0.34 (0.11–1.05) 34 0.06 0.28
Control imaging
US 8 0.58 (0.36–0.92) 18 0.02
CEUS 7 0.62 (0.45–0.86) 21 0.004 0.79
Mean tumor diameter (mm)
<19 8 0.69 (0.46–1.05) 34 0.08
≥19 7 0.51 (0.36–0.71) 0 <0.001 0.26
3DUS, three-dimension ultrasound; CEUS, contrast-enhanced ultrasound; CI, confidence interval; CT, computed tomography; FI, fusion imaging; LTP, local
tumor progression; MRI, magnetic resonance imaging; RR, risk ratio; TER, technology efficacy rate; US, ultrasound.

the differences in safety and efficacy between the two
imaging-based ablation strategies. Second, although one
of the studies was an RCT, the others were all cohort
studies that matched the baseline characteristics between
patients allocated to FI or ultrasound-guided procedures,
thereby minimizing the potential confounding effects of
these factors on the outcome. In addition, this meta-analysis
summarized and reported three outcomes, which showed a
reduced incidence of complications and a decreased risk of
LTP in the FI-guided group despite similar TER, indicating
the superiority of FI-guided ablation to ultrasound-guided
ablation in safety and efficacy. Finally, multiple subgroup
analyses showed that the results were consistent for CT/
MRI and 3DUS based FI, in comparison to conventional
ultrasound or CEUS-guided ablation and in studies with
HCC tumor lesion <19 mm and ≥19 mm. These results
further validated the robustness of the findings.
Collectively, the results of the meta-analysis support the
use of FI-guided thermal ablation for patients with HCC,
particularly for those with difficult tumors under conven-
tional ultrasound-guided ablation.
There are several potential advantages of FI compared to
conventional ultrasound imaging as the guidance for percu-
taneous thermal ablation for HCC. First, by combining mul-
tiple imaging modalities with real-time ultrasound, FI could
theoretically increase the visualizability of the HCC lesions,
which have poor conspicuity on conventional ultrasonog-
raphy. Early studies showed that FI based on CT/MRI-US
could identify HCC lesions that had poor conspicuity on
grayscale ultrasonography or CEUS, suggesting the bene-
fits of FI in locating the HCC lesions and determining the
position for needling (40,41). In addition, during the pro-
cedure, the use of CT/MR-US-based FI has been demon-
strated to be feasible for evaluating RFA and enables
intraoperative treatment evaluation by measuring the abla-
tion margin accurately without needing contrast-enhanced
CT (42). Accordingly, immediate evaluation of the thera-
peutic efficacy could be achieved by FI, and supplemental
ablation sessions could be performed, if necessary, which
may be an important reason for the reduced LTP following
FI-guided ablation. In addition, by incorporating CT with
contrast-enhance or 3DUS, FI could provide further imaging
Sheng et al. 2515

Fig. 3. An analysis of the publication bias of the meta-analyses based on funnel plots: (a) funnel plots for the meta-analysis of TER; (b)
funnel plots for the meta-analysis of the incidence of complications; and (c) funnel plots for the meta-analysis of the risk of LTP during
follow-up of the patients. LTP, local tumor progression; TER, technique efficacy rate.
2516
information regarding the relative locations of adjacent vital
structures, which may be helpful in avoiding organ injury
and severe complications during the ablation (34). Finally,
in addition to increasing tumor detection, FI techniques
improve the confidence of the operator as well as reduce oper-
ating time, which is also an important reason for the use of
FI-guided ablation in patients with HCC (43). However, it
has to be mentioned that FI is still in the development stage,
and it has not been possible to perfectly resolve the inherent
image distortion between ultrasound and CT/MR images.
Efforts are needed to determine the optimized FI strategies
for percutaneous ablation of HCC lesions.
The present study has some limitations. First, only one
of the included studies was a RCT, and the others were
all observational studies. We could not exclude the poten-
tial influences of the unmatched confounding factors on
the outcome of the meta-analysis. Therefore, large-scale
RCTs are needed to validate the findings of the
meta-analysis. Moreover, studies were performed mostly
in China and Japan. Studies from other countries are
needed to confirm these results. Finally, as mentioned pre-
viously, the optimal FI strategy for guiding the thermal
ablation of HCC remains to be developed in future studies.
In conclusion, the results of the meta-analysis demon-
strate that FI-guided thermal ablation may be more effective
and safer than ultrasound-guided ablation for patients with
HCC. Although large-scale RCTs are needed to validate
these findings and determine the long-term survival benefits
of FI-guided ablation for patients with HCC, these findings
support the use of FI as the guiding imaging for thermal
ablation of HCC lesions.
Authors’ note
Jiankui Luan is co-corresponding author and his information is
stated as follows: Jiankui Luan, Department of Medical
Imaging, Laizhou People’s Hospital, 1718 Wuli Street, Laizhou
City, PR China, Email: lzsszsjj@vip.163.com.
Availability of data
The original contributions presented in the study are included in the
article, further inquiries can be directed to the corresponding author.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by the Research project of Qingdao University
Medical Group Co., Ltd. (grant number YLJT20222031).
ORCID iD
Deyin Zhai https://orcid.org/0009-0003-2489-8636
Acta Radiologica 64(9)
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