Habitat imaging before transarterial chemoembolization in hepatocellular carcinoma: Ready for clinical decision-making?

Abstract

Transarterial chemoembolization is an important treatment for intermediate-stage hepatocellular carcinoma. However, a significant challenge in daily clinical practice is identifying which patients are most likely to benefit from this treatment. Conventional imaging and standard clinical and radiological variables often do not capture the full biological complexity of these tumors. This is especially true for the intratumoral heterogeneity that can affect both treatment sensitivity and resistance. Habitat imaging offers a different approach to this challenge by partitioning the tumor into spatially distinct subregions that may reflect variations in perfusion, necrosis, cellularity and treatment vulnerability. The recent study suggests that magnetic resonance imaging-based habitat analysis may improve early response prediction when integrated with radiomic and clinical features. At the same time, this potential should be interpreted with caution. Important limitations remain, including protocol dependence, segmentation variability, limited multicentre reproducibility, uncertain biological correlates and the lack of prospective utility studies. In our view, the relevance of habitat imaging lies not only in improving predictive models, but also in its potential to support treatment allocation before therapy, reduce futile transarterial chemoembolization and strengthen multidisciplinary decision-making. This opinion review discusses the biological rationale, the currently available evidence, the main practical barriers and the further steps required before habitat imaging can become a clinically useful tool in hepatocellular carcinoma.

Keywords: Habitat imaging; Hepatocellular carcinoma; Transarterial chemoembolization; Magnetic resonance imaging; Radiomics; Tumor heterogeneity; Treatment response; Precision medicine

Core Tip: Habitat imaging offers a different way of reading magnetic resonance imaging in hepatocellular carcinoma, moving beyond simple lesion description and trying to capture the tumor’s internal spatial heterogeneity. Its value lies not only in the possibility of predicting response after transarterial chemoembolization, but also in helping clinicians think more carefully about pretreatment selection and multidisciplinary treatment planning. At present, however, this approach is still constrained by important limitations, including methodological fragility, poor standardization, and the lack of solid prospective validation. The key issue is no longer whether habitat imaging is conceptually attractive, but whether it is robust enough to become genuinely useful in clinical practice.