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: [email protected]
Sheng et al. 2507

the incidence of local tumor progression (LTP) during Selection of studies

follow-up (6,7). However, not all HCC lesions were with
The PICOS criteria were used for study inclusion.
adequate visibility on conventional ultrasound, such as
P (patients): patients with a confirmed diagnosis of HCC
those with small size (diameter <2 cm), with the isoechoic
who were planned to receive percutaneous thermal ablation;
feature, or in difficult locations within the body (8,9).
I (intervention or exposure): ablation guided by FI,
Although contrast-enhanced ultrasound (CEUS) has been
including CT/MRI or 3DUS fusion with ultrasound;
suggested to overcome some shortcomings of conven-
C (control): ablation guided by conventional ultrasound
tional ultrasound in guiding the ablation of HCC for
or CEUS;
tumors with inadequate blood supply, the application of
O (outcomes): reported at least one of the following out-
CEUS was restricted (10).
comes, which included the technique efficacy rate (TER),
With the development of digital and three-dimensional
incidence of complications, and risk of LTP during
(3D) imaging techniques in recent years, fusion imaging
follow-up. This study defined technique effectiveness as
(FI) has emerged as a more accurate and efficient tool to
the complete destruction of the macroscopic tumor as deter-
support mini-invasive procedures, including percutaneous
mined by imaging immediately after the procedure (4).
ablation for HCC lesions (11,12). By combining real-time
Complications were defined according to the criteria of
ultrasound or CEUS images with high-resolution images,
the original studies. In addition, LTP was defined as an
such as computed tomography (CT), magnetic resonance
incompletely treated tumor that continues to grow or a
imaging (MRI), or 3D ultrasound (3DUS), FI has been sug-
new tumor (or satellite tumors) that grows at the original
gested to confer more efficiencies than conventional ultra-
site (34).
sound in visualizing the target lesion, determining the
S (study design): cohort studies or randomized con-
ablation edge, and evaluating the therapeutic efficacy of per-
trolled trials (RCTs) published as full-length articles in
cutaneous ablation for HCC (13–15). However, the clinical
peer-reviewed journals.
evidence of the potential superiority of FI-guided thermal
The following studies were excluded: preclinical studies;
ablation to ultrasound-guided ablation remains limited. A
review articles; editorials; meta-analyses; studies that did
few head-to-head comparative studies have been performed.
not include patients with HCC; studies without an interven-
However, these studies have limited sample sizes, and a
tion of FI-guided thermal ablation; studies without a control
summarized study with meta-analysis is needed (16–30).
ultrasound-guided ablation; and studies that did not report
Accordingly, we performed a systematic review and
any of the above outcomes. Studies with the largest
meta-analysis in this study to compare the efficacy and
sample sizes were included in the meta-analysis if multiple
safety of FI versus ultrasound-guided thermal ablation
studies with overlapped patients were retrieved.
for HCC.

Material and Methods Data collection and study quality assessment

This study adhered to the Preferred Reporting Items for Two independent authors searched, collected, and assessed
Systematic Reviews and Meta-Analyses (PRISMA 2020) guide- the data. Discussions with the corresponding author were
line (31,32) and the Cochrane Handbook for Systematic Reviews used to resolve disagreements. The data collected were as
and Meta-analyses (Handbook for Systematic Reviews and follows: (i) author, year, location, and study design; (ii) par-
Meta-analysis) (33). Approval from the Institutional Review ticipant characteristics, such as diagnosis, patient number,
Board was not required as this is a meta-analysis. 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)
Literature search follow-up durations and outcomes reported. An assessment
We obtained studies by searching several databases including of study quality was conducted according to the
Medline, Web of Science, Cochrane Library, and Embase Newcastle-Ottawa Scale (NOS) (35). Based on this scale,
with a combined keyword strategy: (i) “hepatocellular” OR each study was rated using three broad criteria: selection
“liver” OR “hepatic”; (ii) “carcinoma” OR “cancer” OR of the study groups; the comparability of the groups; and
“tumor” OR “malignancy” OR “malignant” OR “neoplasm”; the ascertainment of the outcome of interest. The total
(iii) “ablation” OR “radiofrequency” OR “thermal ablation” score was in the range of 1–9, and a higher score indicated
OR “microwave ablation” OR “RFA”; and (iv) “fusion” OR better study quality. The Cochrane Risk of Bias Tool was
“fusion imaging.” The included studies were published in used to determine the quality of the included RCTs (33)
English and involved human particiants. To complement according to the following aspects: assigning random
this process, we hand-screened the citations of the related ori- sequences; concealing allocations; blinding participants
ginal and review articles. Literature searches were last con- and personnel; blinding outcomes assessors; incomplete
ducted on 30 December 2022. 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 Acta Radiologica 64(9)

Statistical methods ablation and 1380 patients (1864 tumors) for ultrasound-
guided ablation. These studies were published between
In the present study, the outcome of categorized variables
2014 and 2022, and were performed in Japan, China, and
was presented as risk ratio (RR) and 95% confidence inter-
Austria. All the studies included patients with HCC who
val (CI) (36). An evaluation of the extent of heterogeneity
were allocated to an intervention group of patients with
between studies was conducted by performing Cochrane’s
FI-guided percutaneous thermal ablation and a control
Q test and estimating the I2 statistic, as explained previously
group of patients with ultrasound (conventional ultrasound
(36,37). An I2 > 50% indicates heterogeneity. The results
or CEUS) guided ablation. The number of included patients
were pooled using a random-effects model that considered
was in the range of 28–839 in the included studies. The
possible between-study heterogeneity (33). For studies
mean age of the included patients was in the range of 52–
including multiple intervention groups of different strat-
73 years. The mean diameter of the tumors was in the
egies for FI (e.g. CT/MRI-US and 3DUS-US), the control
range of 14–41 mm. As for the ablation procedures, RFA
groups with ultrasound-guided ablation were equally split
was used in eight studies (16,17,22,24–28), MWA was
and included as independent comparisons to overcome a
used in one study (21), and RFA or MWA was used in
unit-of-analysis error, according to the instruction of
the remaining six studies (18–20,23,29,30). The median
Cochrane’s Handbook (33). Whenever possible, predefined
follow-up durations were 8–66 months, and variables
subgroup analyses were performed according to the differ-
such as age, sex, Child-Pugh Score, etiology, tumor size,
ent strategies for FI, ultrasound techniques in control (ultra-
location, and so on were matched between patients with
sound or CEUS), and mean diameters of the tumors. A
FI and ultrasound-guided ablation. For the cohort studies
median of the continuous variable was selected as a
(16,17,19–30), the included studies received a NOS of 7–
cutoff for defining subgroups. To determine whether publi-
9 stars, which indicates good study quality (Table 2). For
cation bias exists, funnel plots were constructed and visu-
the RCT (18), the details of random sequence generation
ally examined for symmetry (38). In addition, for the
were reported, but not for the details of allocation conceal-
purpose of testing for publication bias, Egger’s regression
ment. The study was blinded to the outcome assessment but
analysis was conducted (38). RevMan (version 5.1;
to the patient.
Cochrane Collaboration, Oxford, UK) and Stata were
used for the statistical analysis. P < 0.05 indicates statistical
significance.
Meta-analysis results
Pooled results of 15 comparisons from 14 studies (16–
Results
21,23–30) indicated that compared to conventional HCC
Study retrieval ablation guided by ultrasound, FI-guided procedure
showed similar TER (RR = 1.01, 95% CI = 1.00–1.02, P
As shown in Fig. 1, after a search of electronic databases, = 0.25) (Fig. 2a) with mild heterogeneity (p for
675 articles were retrieved, and 544 remained after duplica- Cochrane’s Q test = 0.13, I2 = 30%). Sensitivity analyses
tions were removed. Among the 544 titles and abstracts by excluding one dataset at a time showed consistent
screened for the meta-analysis, 491 were excluded due to results (RR = 1.00 or 1.01, P all >0.05). However, evidence
their non-compliance with the criteria of the meta-analysis. from 12 studies (16,18–25,27,28,30) showed that FI-guided
Of the remaining 53 studies, 38 were subsequently tumor ablation was associated with a lower incidence of
excluded due to the reasons listed in Fig. 1 after full texts overall complications (RR = 0.70, 95% CI = 0.50–0.97,
were read by two authors independently. As a result, 15 P = 0.03) (Fig. 2b) with no significant heterogeneity
studies were enrolled in the meta-analysis (16–30). (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
Study characteristics meta-analysis with 14 studies suggested that patients
Table 1 summarizes the characteristics of the studies receiving FI-guided tumor ablation had a lower risk of
included in the meta-analysis. Overall, one RCT (18), LTR during follow-up compared to those with ultrasound-
three prospective cohort studies (17,19,27), and 11 retro- guided ablation (RR = 0.61, 95% CI = 0.47–0.78, P <
spective cohort studies (16,20–26,28–30) were available. 0.001) (Fig. 2c) with mild heterogeneity (p = 0.31, I2 =
Since one study included two comparisons of different FI 13%). The results were consistent for sensitivity analysis
techniques with ultrasound (CT/MR-CEUS vs. CEUS and by excluding one dataset sequentially (RR = 0.56–0.66, P
3DUS-CEUS vs. CEUS) (18), these datasets were included all <0.05). Subgroup analysis according to the difference
independently in the meta-analysis. Accordingly, 16 com- of FI strategy, imaging techniques in controls, and tumor
parisons (datasets) were available for this meta-analysis, diameter showed consistent results for the meta-analyses
involving 1472 patients (1831 tumors) for FI-guided of TER, the incidence of complications, and the risk of
Sheng et al. 2511

Fig. 1. Diagram illustrating the process of searching databases and identifying studies.

LTP during follow-up (P for subgroup difference all >0.05) had a similar TER. However, FI-guided thermal ablation
(Table 3). 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
Publication bias analyses by excluding one study at a time and in subgroup
The funnel plots for the meta-analyses of TER, the inci- analyses according to the different strategies in FI, control
dence of complications, and the risk of LTP during images, and mean diameter of the tumors. Taken together,
follow-up are shown in Figs. 3a–c. There are low publica- although large-scale RCTs are needed to validate these find-
tion bias risks based on the plots’ symmetry for these ings, the results of the meta-analysis indicate that guided
meta-analyses. Moreover, Egger’s regression tests did not thermal ablation may be more effective and safer than
reveal any significant publication bias (P values all >0.10). 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
Discussion RFA for patients with HCC (39). This meta-analysis
In this systematic review and meta-analysis, we pooled the included only six relevant studies published before April
results of 15 available studies, and the results showed that 2021, with a total of 1168 patients with HCC. Although
compared to percutaneous thermal ablation guided with this study showed a similar TER for FI and ultrasound-
ultrasound or CEUS, FI-guided thermal ablation for HCC 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 There are several potential advantages of FI compared to
imaging-based ablation strategies. Second, although one conventional ultrasound imaging as the guidance for percu-
of the studies was an RCT, the others were all cohort taneous thermal ablation for HCC. First, by combining mul-
studies that matched the baseline characteristics between tiple imaging modalities with real-time ultrasound, FI could
patients allocated to FI or ultrasound-guided procedures, theoretically increase the visualizability of the HCC lesions,
thereby minimizing the potential confounding effects of which have poor conspicuity on conventional ultrasonog-
these factors on the outcome. In addition, this meta-analysis raphy. Early studies showed that FI based on CT/MRI-US
summarized and reported three outcomes, which showed a could identify HCC lesions that had poor conspicuity on
reduced incidence of complications and a decreased risk of grayscale ultrasonography or CEUS, suggesting the bene-
LTP in the FI-guided group despite similar TER, indicating fits of FI in locating the HCC lesions and determining the
the superiority of FI-guided ablation to ultrasound-guided position for needling (40,41). In addition, during the pro-
ablation in safety and efficacy. Finally, multiple subgroup cedure, the use of CT/MR-US-based FI has been demon-
analyses showed that the results were consistent for CT/ strated to be feasible for evaluating RFA and enables
MRI and 3DUS based FI, in comparison to conventional intraoperative treatment evaluation by measuring the abla-
ultrasound or CEUS-guided ablation and in studies with tion margin accurately without needing contrast-enhanced
HCC tumor lesion <19 mm and ≥19 mm. These results CT (42). Accordingly, immediate evaluation of the thera-
further validated the robustness of the findings. peutic efficacy could be achieved by FI, and supplemental
Collectively, the results of the meta-analysis support the ablation sessions could be performed, if necessary, which
use of FI-guided thermal ablation for patients with HCC, may be an important reason for the reduced LTP following
particularly for those with difficult tumors under conven- FI-guided ablation. In addition, by incorporating CT with
tional ultrasound-guided ablation. 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 Acta Radiologica 64(9)

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