Limited Added Prognostic Value of Choline PET/CT in Treatment-Naïve Hepatocellular Carcinoma

This retrospective study aimed to assess whether choline PET/CT provides additional independent prognostic value compared with magnetic resonance imaging (MRI) and [ ¹⁸ F]FDG PET/CT in treatment-naïve patients with hepatocellular carcinoma (HCC). A total of 78 treatment-naïve patients with predominantly single-lesion and early-stage HCC who underwent MRI, [ ¹⁸ F]FDG PET/CT, and choline PET/CT were retrospectively included.

Higher than median MRI-, choline and [ ¹⁸ F]FDG PET/CT-derived tumor volumes were associated with poorer overall survival (OS) in univariate analyses. An MRI-derived tumor volume > 17.81 mL was associated with worse OS ( p  = 0.005; hazard ratio [HR], 3.15; 95% confidence interval [CI], 1.41-7.03), as were choline PET/CT tumor volume > 8.4 mL ( p  = 0.04; HR, 2.27; 95% CI, 1.03-5.01) and [ ¹⁸ F]FDG positivity ( p  = 0.02; HR, 2.74; 95% CI, 1.11-6.81). After multivariate analysis with correction for multiple testing, only MRI-derived tumor volume remained an independent predictor of OS. Although associated with OS in univariate analyses, choline PET-derived metrics did not retain statistical significance after adjustment, suggesting limited incremental prognostic information beyond MRI-derived tumor burden. Liver transplantation and hepatectomy were associated with superior survival compared with locoregional therapies ( p  = 0.006). No significant correlations were observed between imaging parameters and α-fetoprotein (AFP) levels or ALBI score (all p  > 0.05). Interaction analyses did not detect any significant modification of the prognostic effect of choline PET imaging biomarkers by AFP levels, ALBI score, or Child-Pugh class. Treatment modality emerged as the strongest prognostic factor in the penalized model using least absolute shrinkage and selection operator regularization, while choline PET-derived parameters did not show independent prognostic value.

Choline PET/CT did not demonstrate additional independent prognostic value beyond MRI or [ ¹⁸ F]FDG PET/CT in this cohort of treatment-naïve patients with predominantly early-stage and single-lesion HCC.