A pilot comparison of 18F-fluorodeoxyglucose and 18F-fluorocholine PET/CT to predict early recurrence of unifocal hepatocellular carcinoma after surgical resection. Nucl Med Commun. 2012;33:757-765. [PMID: 22504293 DOI: 10.1097/mnm.0b013e328350fb9f]

Update on PET Radiopharmaceuticals for Imaging Hepatocellular Carcinoma

Numerous positron emission tomography (PET) targets for detection and staging of hepatocellular cancer have been developed in recent years. Hepatocellular carcinomas (HCCs) are clinically and pathologically heterogeneous tumours with a high tendency to be aggressive and unresponsive to chemotherapy. Early detection is essential, and the need for an adequate imaging biomarker, which can overcome some of the limitations of conventional radiological imaging, is persistent. Flourine-18 (18F) flourodeoxyglucose (FDG), the most widely used PET radiopharmaceutical, has proven disappointing as a possible staple in the evaluation of HCC. This disappointment had led to experimentation with carious radiotracers, such as the choline derivatives, acetate, and prostate-specific membrane antigen, which appear to complement and/or enhance the role of FDG. In this study, we look at the various PET radiopharmaceuticals that have been used for imaging HCC and the particular pathways that they target in HCC and liver cancers.

18F-FDG /18F-Choline Dual-Tracer PET Behavior and Tumor Differentiation in HepatoCellular Carcinoma. A Systematic Review

Background

Post-operative recurrence remains the strongest prognostic factor of resected hepatocellular carcinoma (HCC), making the accurate selection of patients with curable HCC a crucial issue. PET imaging combining both 18F-FDG and fatty acid synthase (FAS) radiotracers—such as Choline—has shown its interest for the initial staging and therapeutic management of patients with HCC, but its use is still not consensual. Importantly, the very first dual-tracer PET studies suggested 18F-FDG/FAS PET behavior be linked to the degree of differentiation of HCC, a major predictive factor of post-operative recurrence. Although this key molecular imaging concept may impact how dual-tracer PET will be used in early-stage HCC, its level of evidence remains largely unexplored. In this study, we conducted a systematic review of the available evidence-based data to clarify the relevance of dual 18F-FDG/18F-Choline PET in characterizing the degree of differentiation of HCC tumors.

Methods

A systematic search of the PubMed/Medline and Embase databases was performed up to November 2021. A systematic review of the dual-tracer 18F-FDG/18F-Choline PET behavior of histology-proven HCC according to their degree of differentiation was conducted. The overall quality of the included studies was critically assessed based on the STROBE guidelines. Information on study date, design, patient cohort characteristics, grade of differentiation of HCC tumors, and the dual-tracer PET behavior per HCC was independently extracted and summarized.

Results

From 440 records initially available, 6 full-text articles (99 histology-proven HCC) provided dual-tracer 18F-FDG/18F-Choline PET behavior per HCC tumor grade were included in the systematic review. Based on our analysis, 43/99 HCCs were reported to be well-differentiated, and 56/99 HCCs were reported to be less-differentiated tumors. In the well-differentiated subgroup, more than half were exclusively positive for 18F-Choline (51%), whereas 39% were positive for both 18F-FDG and 18F-Choline. In the less-differentiated subgroup, 37% of HCC patients were positive exclusively for FDG, 36% were positive for both 18F-FDG and 18F-Choline, and 25% were positive exclusively for 18F-Choline.

Conclusion

The 18F-FDG/18F-Choline dual-tracer PET behavior of uptake shows high overlap between well- and less differentiated HCC, making the characterization of tumors challenging based on such PET combination alone. Given our growing knowledge of the molecular complexity of HCC, further studies are necessary to refine our understanding of radiotracers’ behavior in this field and improve the usefulness of PET imaging in the clinical decision process of HCC.

Metabolism-Associated Gene Signatures for FDG Avidity on PET/CT and Prognostic Validation in Hepatocellular Carcinoma

Introduction

The prognostic value of F-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) in hepatocellular carcinoma (HCC) was established in previous reports. However, there is no evidence suggesting the prognostic value of transcriptomes associated with tumor FDG uptake in HCC. It was aimed to elucidate metabolic genes and functions associated with FDG uptake, followed by assessment of those prognostic value.

Methods

Sixty HCC patients with Edmondson–Steiner grade II were included. FDG PET/CT scans were performed before any treatment. RNA sequencing data were obtained from tumor and normal liver tissue. Associations between each metabolism-associated gene and tumor FDG uptake were investigated by Pearson correlation analyses. A novel score between glucose and lipid metabolism-associated gene expression was calculated. In The Cancer Genome Atlas Liver Hepatocellular Carcinoma dataset, the prognostic power of selected metabolism-associated genes and a novel score was evaluated for external validation.

Results

Nine genes related to glycolysis and the HIF-1 signaling pathway showed positive correlations with tumor FDG uptake; 21 genes related to fatty acid metabolism and the PPAR signaling pathway demonstrated negative correlations. Seven potential biomarker genes, PFKFB4, ALDOA, EGLN3, EHHADH, GAPDH, HMGCS2, and ENO2 were identified. A metabolic gene expression balance score according to the dominance between glucose and lipid metabolism demonstrated good prognostic value in HCC.

Conclusions

The transcriptomic evidence of this study strongly supports the prognostic power of FDG PET/CT and indicates the potential usefulness of FDG PET/CT imaging biomarkers to select appropriate patients for metabolism-targeted therapy in HCC.

Differential Diagnosis of Hepatic Mass with Central Scar: Focal Nodular Hyperplasia Mimicking Fibrolamellar Hepatocellular Carcinoma

Fibrolamellar hepatocellular carcinoma is a primary hepatic tumor that usually appears in young adults. Radical surgery is considered curative for this kind of tumor, so early diagnosis becomes essential for the prognosis of the patients. The main characteristic of this entity is the central scar, which is the center of differential diagnosis. We report the case of a 30-year-old man who was diagnosed with fibrolamellar hepatocellular carcinoma by ultrasonography. Contrast-enhanced CT confirmed this diagnosis, and the patient underwent a [18F] fluorocholine PET/CT. Hypermetabolism and the morphology in the nuclear medicine exploration suggest neoplastic nature of the lesion. Radical surgery was performed, and histopathologic analysis was performed, which resulted in focal nodular hyperplasia. Hepatic masses with central scar could have a difficult differential diagnosis, and focal nodular hyperplasia could mimic fibrolamellar hepatocellular carcinoma imaging patterns. These morphofunctional characteristics have not been described in [18F] Fluorocholine PET/CT, so there is a need to find out the potential role PET/CT in the differential diagnosis of hepatic mass with central scar.

Incidental Finding on 11C-Choline-PET/CT of Hepatocellular Carcinoma Recurrence in a Prostate Cancer Patient With Negative Abdominal CT Scan

A 76-year-old man, who experienced prostate cancer biochemical relapse after 12 years from radical prostatectomy, underwent abdominal CT scan for restaging purposes, negative for metastases, and then C-choline PET/CT. The only finding was an area of focal uptake of radiotracer between the intestinal loops and the abdominal wall; after resection, the lesion demonstrated to be a metastasis from hepatocellular carcinoma (HCC), for which the patient had undergone liver resection 2 years earlier. This case proves that abnormal foci of C-choline uptake in the peritoneum in HCC patients have to be kept in mind as possible sites of HCC-metastases.

Importance of PET/CT examination in patients with malignant uveal melanoma

INTRODUCTION

Diagnostic and therapeutic management of the patient with malignant uveal melanoma (MMU) is subject to ongoing efforts to innovate. PET/CT (Positron Emission Tomography / Computed Tomography) examination is important in both diagnosis and metastases.

MATERIAL AND METHODS

Evaluation of the importance of PET/CT examination in the group of patients diagnosed with MMU in the period 12.1.2016 to 6.12.2018. All patients with a diagnosis of secondary retinal detachment, suspected uveal melanoma, underwent standard examinations to detect possible metastases (liver ultrasound, chest X-ray). Patients for whom a stereotactic radiosurgery solution was planned due to the stage of the disease this examination was to exclude metastasis in the liver or lungs. PET/CT examination is part of the protocol within the exclusion criteria for treatment with stereotactic radiosurgery in one day session surgery.

RESULTS

In the group of 84 patients, 47 women (56 %) and 37 men (44 %) were aged between 26 and 90 years. Their average age was 61.4 years. The median group was 64 years, modus 65 years. Of 84 patients, 79 (94 % of cases) had a diagnosis of C69.3 (choroidal melanoma) and 5 patients (6 % of cases) had a diagnosis of C69.4 (ciliary body melanoma). Subsequent PET/CT examination in many patients did not reveal hypermetabolic manifestations that could involve various pathological processes, in others the radiopharmaceutical was captured in the primary tumor area of the uveal tract. Hypermetabolism in eye globe was only found in melanomas with a volume of more than 0.5 cm3. PET/CT examinations were 85, with one patient undergoing examination twice. However, in 25 patients (26 examinations), the radiopharmaceutical was taken up in places that subsequently required closer attention. The initial aim of the examination was to locate possible metastases of MMU. In the others, 3 incidents have been reported: increased metabolism in the lung and liver, thyroid and mediastinal lymph nodes. Of the 85 examinations, 26 (30.6 %) resulted in a hypermetabolic manifestation of accumulation, which was not located in the eye tract, resp. right in the eye. Two malignancies (prostatic carcinoma and rectosigmal carcinoma) have occurred in two patients. Very important was the discovery of MMU metastasis in the liver, which confirmed the important role of PET/CT examination in the management of MMU patients. The metastasis was discovered after repeated PET/CT examination.

CONCLUSION

PET/CT examination is a technically demanding examination and is one of the possibilities of imaging intraocular melanoma in tumors with volume more than 0.5 cm3. It is important in determining the grading and staging of the disease before radiosurgical treatment and also in detecting possible metastases after MMU treatment in cases where ultrasound or MRI examinations do not give a definite result. However, our study confirmed the significance of this examination for randomly detected 2 duplex malignancies (2.4%) and 3 incidentalomas (3.6%) in patients whose ophthalmologist diagnosed uveal melanoma and sent patients for full-body PET/CT examination.

Hepatocellular Carcinomas With Mutational Activation of Beta-Catenin Require Choline and Can Be Detected by Positron Emission Tomography

BACKGROUND & AIMS

In one-third of hepatocellular carcinomas (HCCs), cancer cells have mutations that activate β-catenin pathway. These cells have alterations in glutamine, bile, and lipid metabolism. We investigated whether positron emission tomography (PET) imaging allows identification of altered metabolic pathways that might be targeted therapeutically.

METHODS

We studied mice with activation of β-catenin in liver (Apc^ko-liv mice) and male C57Bl/6 mice given injections of diethylnitrosamine, which each develop HCCs. Mice were fed a conventional or a methionine- and choline-deficient diet or a choline-deficient (CD) diet. Choline uptake and metabolism in HCCs were analyzed by micro-PET imaging of mice; livers were collected and analyzed by histologic, metabolomic, messenger RNA quantification, and RNA-sequencing analyses. Fifty-two patients with HCC underwent PET imaging with ¹⁸F-fluorodeoxyglucose, followed by ¹⁸F-fluorocholine tracer metabolites. Human HCC specimens were analyzed by immunohistochemistry, quantitative polymerase chain reaction, and DNA sequencing. We used hepatocytes and mouse tumor explants for studies of incorporation of radiolabeled choline into phospholipids and its contribution to DNA methylation. We analyzed HCC progression in mice fed a CD diet.

RESULTS

Livers and tumors from Apc^ko-liv mice had increased uptake of dietary choline, which contributes to phospholipid formation and DNA methylation in hepatocytes. In patients and in mice, HCCs with activated β-catenin were positive in ¹⁸F-fluorocholine PET, but not ¹⁸F-fluorodeoxyglucose PET, and they overexpressed the choline transporter organic cation transporter 3. The HCC cells from Apc^ko-liv mice incorporated radiolabeled methyl groups of choline into phospholipids and DNA. In Apc^ko-liv mice, the methionine- and choline-deficient diet reduced proliferation and DNA hypermethylation of hepatocytes and HCC cells, and the CD diet reduced long-term progression of tumors.

CONCLUSIONS

In mice and humans, HCCs with mutations that activate β-catenin are characterized by increased uptake of a fluorocholine tracer, but not ¹⁸F-fluorodeoxyglucose, revealed by PET. The increased uptake of choline by HCCs promotes phospholipid formation, DNA hypermethylation, and hepatocyte proliferation. In mice, the CD diet reverses these effects and promotes regression of HCCs that overexpress β-catenin.

Transcriptomics Associates Molecular Features with 18F-Fluorocholine PET/CT Imaging Phenotype and Its Potential Relationship to Survival in Hepatocellular Carcinoma

Studies involving transcriptomics have revealed multiple molecular subtypes of hepatocellular carcinoma (HCC). Positron emission tomography/computed tomography (PET/CT) has also identified distinct molecular imaging subtypes, including those with increased and decreased choline metabolism as measured by the tissue uptake of the radiopharmaceutical ¹⁸F-fluorocholine. Gene signatures reflecting the molecular heterogeneity of HCC may identify the biological and clinical significance of these imaging subtypes. In this study, 41 patients underwent ¹⁸F-fluorocholine PET/CT, followed by tumor resection and gene expression profiling. Over- and underexpressed components of previously published gene signatures were evaluated for enrichment between tumors with high and low ¹⁸F-fluorocholine uptake using gene set analysis. Significant gene sets were enumerated by FDR based on phenotype permutation. Associations with overall survival were analyzed by univariate and multivariate proportional hazards regression. Ten gene sets related to HCC were significantly associated with high tumor ¹⁸F-fluorocholine uptake at FDR q < 0.05, including those from three different clinical molecular classification systems and two prognostic signatures for HCC that showed predictive value in the study cohort. Tumor avidity for ¹⁸F-fluorocholine was associated with favorable characteristics based on these signatures with lower mortality based on survival analysis (HR 0.36; 95% confidence interval, 0.14-0.95). Tumors demonstrating high ¹⁸F-fluorocholine uptake were also enriched for genes involved in oxidative phosphorylation, fatty acid metabolism, peroxisome, bile acid metabolism, xenobiotic metabolism, and adipogenesis. These results provide a pathobiological framework to further evaluate ¹⁸F-fluorocholine PET/CT as a molecular and prognostic classifier in HCC. SIGNIFICANCE: A pathobiological framework for HCC brings together multiple prognostically relevant gene signatures via convergence with ¹⁸F-fluorocholine PET/CT imaging phenotype.

Arterial Phase 18F-Fluorocholine PET/CT in Hepatocellular Carcinoma

A 57-year-old man was referred to our institution for F-fluorocholine PET/CT to characterize a pulmonary nodule in a context of hepatocellular carcinoma. F-FDG PET/CT did not show any uptake of the pulmonary nodule. F-fluorocholine PET/CT showed high uptake of the pulmonary nodule, confirming its metastatic origin. Furthermore, liver early dynamic acquisitions allowed better visualization of the hepatocellular carcinoma during the "arterial phase" than at equilibrium.

Volumetric parameters on FDG PET can predict early intrahepatic recurrence-free survival in patients with hepatocellular carcinoma after curative surgical resection

PURPOSE

This study assessed the prognostic values of volumetric parameters on ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) in predicting early intrahepatic recurrence-free survival (RFS) after curative resection in patients with hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was performed on 242 patients with HCC who underwent staging FDG PET and subsequent curative surgical resection. The tumor-to-non-tumorous liver uptake ratio, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of the HCC lesions on PET were measured. The prognostic values of clinical factors and PET parameters for predicting overall RFS, overall survival (OS), extrahepatic RFS, and early and late intrahepatic RFS were assessed.

RESULTS

The median follow-up period was 54.7 months, during which 110 patients (45.5%) experienced HCC recurrence and 62 (25.6%) died. Patients with extrahepatic and early intrahepatic recurrence showed worse OS than did those with no recurrence or late intrahepatic recurrence (p < 0.001). Serum bilirubin level, MTV, and TLG were independent prognostic factors for overall RFS and OS (p < 0.05). Only MTV and TLG were prognostic for extrahepatic RFS (p < 0.05). Serum alpha-fetoprotein and bilirubin levels, MTV, and TLG were prognostic for early intrahepatic RFS (p < 0.05) and hepatitis C virus (HCV) positivity and serum albumin level were independently prognostic for late intrahepatic RFS (p < 0.05).

CONCLUSION

Intrahepatic recurrence showed different prognoses according to the time interval of recurrence in which early recurrence had as poor survival as extrahepatic recurrence. MTV and TLG on initial staging PET were significant independent factors for predicting early intrahepatic and extrahepatic RFS in patients with HCC after curative resection. Only HCV positivity and serum albumin level were significant for late intrahepatic RFS, which is mainly attributable to the de novo formation of new primary HCC.

The value of [11C]-acetate PET and [18F]-FDG PET in hepatocellular carcinoma before and after treatment with transarterial chemoembolization and bevacizumab

Purpose

This prospective study was to investigate the value of [¹¹C]-acetate PET and [¹⁸F]-FDG PET in the evaluation of hepatocellular carcinoma (HCC) before and after treatment with transarterial chemoembolization (TACE) and vascular endothelial growth factor (VEGF) antibody (bevacizumab).

Methods

Twenty-two patients (three women, 19 men; 62 ± 8 years) with HCC verified by histopathology were treated with TACE and bevacizumab (n = 11) or placebo (n = 11). [¹¹C]-acetate PET and [¹⁸F]-FDG PET were performed before and after TACE with bevacizumab or placebo. Comparisons between groups were performed with t-tests and Chi-squared tests, where appropriate. Overall survival (OS) was defined as the time from start of bevacizumab or placebo until the date of death/last follow-up, respectively.

Results

The patient-related sensitivity of [¹¹C]-acetate PET, [¹⁸F]-FDG PET, and combined [¹¹C]-acetate and [¹⁸F]-FDG PET was 68%, 45%, and 73%, respectively. There was a significantly higher rate of conversion from [¹¹C]-acetate positive lesions to negative lesions in patients treated with TACE and bevacizumab as compared with that in patients with TACE and placebo (p < 0.05). In patients with negative acetate PET, the mean OS in patients treated with TACE and bevacizumab was 259 ± 118 days and was markedly shorter as compared with that (668 ± 217 days) in patients treated with TACE and placebo (p < 0.05). In patients treated with TACE and placebo, there was significant difference in mean OS in patients with positive FDG PET as compared with that in patients with negative FDG PET (p < 0.05). The HCC lesions had different tracer avidities showing the heterogeneity of HCC.

Conclusions

Our study suggests that combining [¹⁸F]-FDG with [¹¹C]-acetate PET could be useful for the management of HCC patients and might also provide relevant prognostic and molecular heterogeneity information.

Prognostic Value of Metabolic Tumor Volume and Total Lesion Glycolysis on Preoperative 18F-FDG PET/CT in Patients With Very Early and Early Hepatocellular Carcinoma

PURPOSE

The aim of this article was to evaluate the prognostic value of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) on preoperative F-FDG PET/CT for predicting intrahepatic recurrence-free survival (IHRFS), extrahepatic metastasis-free survival (EHMFS), and overall survival (OS) in patients with very early/early hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We retrospectively enrolled 132 patients with very early/early HCC who underwent F-FDG PET/CT followed by surgery. The maximum tumor SUV-to-mean normal liver SUV ratio, MTV, and TLG were measured for each patient. Prognostic significances of PET/CT parameters and clinicopathologic factors for IHRFS, EHMFS, and OS were evaluated. Cumulative IHRFS, EHMFS, and OS were calculated using the Kaplan-Meier method.

RESULTS

Thirty-three (25%) and 21 (15.9%) of 132 patients experienced intrahepatic and extrahepatic recurrence, respectively, during a median follow-up period of 38.1 months. In multivariate analysis, none of the factors were significant for IHRFS. Metabolic tumor volume and TLG were only significant factors for EHMFS and OS (P < 0.05). The 5-year EHMFS rates were 94.8% in patients with low MTV and TLG, and 62.1% and 63.2% in patients with high MTV and TLG, respectively (P < 0.001). The 5-year OS rates were 92.6% and 92.4% in patients with low MTV and TLG, and 63.3% and 64.3% in patients with high MTV and TLG, respectively (P < 0.001).

CONCLUSIONS

Metabolic tumor volume and TLG on preoperative PET/CT were independent prognostic factors for EHMFS and OS but not IHRFS in patients with very early/early HCC. Therefore, patients with high MTV or TLG should be closely observed for extrahepatic metastasis using systemic evaluations.

Diagnostic role of radiolabelled choline PET or PET/CT in hepatocellular carcinoma: a systematic review and meta-analysis

The role of fluorine-18-fluorodeoxygluose positron emission tomography/computed tomography ((18)F-FDG PET/CT) in hepatocellular carcinoma (HCC) has not been firmly established yet and its sensitivity has been reported to be in the range of 40-60 %. Because of this relatively low sensitivity alternative tracers have been proposed. The aim of our review is to analyse the literature data on the diagnostic role of (18)F/(11)C-choline PET/CT in the evaluation of HCC. A comprehensive computer literature search of PubMed/MEDLINE, Embase and Scopus databases was conducted to find relevant published articles about the role of whole-body (18)F-choline or (11)C-choline PET or PET/CT in patients with HCC. Furthermore, a meta-analysis about the detection rate of this method in HCC was performed. Six articles were included in this systematic review and discussed. The meta-analysis of five out of six articles showed a DR of 84 % (95 % CI 79-89 %). The DR increased when poorly differentiated HCC was excluded from the analysis. Radiolabelled choline PET or PET/CT could be a valuable tool in detecting HCC and it is better than (18)F-FDG PET/CT, especially in well to moderately differentiated lesions; on the other hand, poorly differentiated and higher-stage HCC could be better evaluated with (18)F-FDG and dual tracer imaging should be considered and could be potentially useful to increase accuracy.

Does 18F-FDG positron emission tomography-computed tomography have a role in initial staging of hepatocellular carcinoma?

Background and Aim

The utility of fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography-computed tomography (PET/CT) in initial staging of hepatocellular carcinoma (HCC) has yet to be fully explored. We assessed the usefulness of ¹⁸F-FDG PET/CT in initial staging of HCC.

Methods

A total of 457 consecutive patients initially diagnosed with HCC at Seoul National University Hospital between 2006 and 2012 were evaluated retrospectively to assess the impact of ¹⁸F-FDG PET/CT on staging and compliancy with Milan criteria, relative to dynamic CT of liver and chest x-ray.

Results

Seven among the 457 patients studied showed a shift in Barcelona Clinic Liver Cancer [BCLC] stage (A→C: 6 patients; B→C: 1 patient) and 5 patients who had originally met Milan criteria no longer qualified. ¹⁸F-FDG PET/CT had value in initial staging of early (stage A) or intermediate (stage B) HCC, as determined by dynamic CT of liver and BCLC or AJCC classifications, whereas BCLC stage 0 and stage C tumors were unchanged (P<0.001). ¹⁸F-FDG PET/CT disclosed additional metastases in patients with American Joint Committee on Cancer [AJCC] T2 (2.7%), T3a (5.3%), and T3b (4.8%) classifications.

Conclusions

In initial staging of HCC, ¹⁸F-FDG PET/CT provided additional information, impacting the patients with BCLC (stages A and B) and AJCC (T2 and T3) classifications. Its use might be thus appropriate for these patient subsets, especially if hepatic resection or liver transplantation is planned.

Nuclear imaging for functional evaluation and theragnosis in liver malignancy and transplantation

Currently, nuclear imaging such as positron emission tomography (PET) and single photon emission computed tomography (SPECT) is increasingly used in the management of liver malignancy. ¹⁸F-fluorodeoxyglucose (FDG)-PET is the most widely used nuclear imaging in liver malignancy as in other cancers, and has been reported to be effective in diagnosis, response monitoring, recurrence evaluation, and prognosis prediction. Other PET imaging such as ¹¹C-acetate PET is also used complementarily to FDG-PET in diagnosis of liver malignancy. Additionally, image-based evaluation of regional hepatic function can be performed using nuclear imaging. Those imaging modalities are also effective for candidate selection, treatment planning, and perioperative evaluation in liver surgery and transplantation. Recently, nuclear imaging has been actively adopted in the transarterial radioembolization therapy of liver malignancy, according to the concept of theragnosis. With the development of new hybrid imaging technologies such as PET/magnetic resonance imaging and SPECT/CT, nuclear imaging is expected to be more useful in the management of liver malignancy, particularly regarding liver surgery and transplantation. In this review, the efficacy and roles of nuclear imaging methods in diagnosis, transplantation and theragnosis are discussed.