Yin Zhou,1,* Junjie Li,2,* Qingshu Li,3,* Liu Liu,1 Ping Huang,4 Yun Mao,1 Yaying Yang,3 Furong Lv,1 Ziyu Liu1 

1Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, People’s Republic of China; 2Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China; 3Department of Pathology, School of Basic Medicine, Chongqing Medical University, Molecular Medicine Diagnostic and Testing Center, Chongqing Medical University, Department of Clinical Pathology Laboratory of Pathology Diagnostic Center, Chongqing Medical University, Chongqing, 400016, People’s Republic of China; 4Department of Hepatobiliary Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China

*These authors contributed equally to this work

Correspondence: Ziyu Liu, Master of Medicine, Department of radiology, the first affiliated hospital of Chongqing medical university, No. 1, Youyi Road, Yuzhong District, Chongqing, People’s Republic of China, 400016, Tel +19942338328, Email liuziyu301@163.com

Purpose: To explore the diagnostic and prognostic value of AI-quantified MRI tumor volume for assessing pathologic response in unresectable hepatocellular carcinoma (uHCC) after hepatic arterial infusion chemotherapy plus targeted therapy and immunotherapy (HAIC-TI).
Materials and Methods: This retrospective study included 35 patients (46 lesions) who underwent HAIC-TI followed by hepatectomy. AI was used to calculate the tumor enhancement volume ratio (TEVR) from MRI. Correlation analysis was conducted to evaluate the relationship between TEVR and pathological tissue proportions. Receiver operating characteristic (ROC) curve determined the optimal cutoff for the ratio of viable tumor cells (RVTCs) to define major pathological response (MPR). The diagnostic performance of AI for MPR and its prognostic significance in recurrence-free survival (RFS) were assessed.
Results: TEVR in portal venous phase is strongly correlated with non-necrotic tissue ratio (r = 0.89, p < 0.001). RVTCs ≤ 10% predicted reduced intrahepatic recurrence (Area Under the Curve [AUC] = 0.808, p < 0.001) and independently associated with prolonged RFS (HR [hazard ratio] = 0.19, 95% CI [confidence interval]: 0.05– 0.69, p = 0.011). TEVR ≤ 19.5% in the portal venous phase demonstrated high diagnostic performance for identifying MPR (AUC = 0.879) and was significantly associated with improved RFS in both univariable analysis (HR = 0.34, 95% CI: 0.12– 1.00, p = 0.049) and the multivariable model incorporating only clinical and imaging factors.
Conclusion: AI-based MRI quantification of TEVR effectively reflected pathologic response and served as a non-invasive prognostic marker for postoperative recurrence in uHCC patients after HAIC-TI.
Plain Language Summary: Why was this study done? After receiving combined chemotherapy, targeted therapy, and immunotherapy for liver cancer, doctors need to accurately assess whether the tumor is responding well. Currently, this requires surgically removing the tumor for microscopic examination (pathological analysis), which cannot provide real-time evaluation during treatment. We aimed to use artificial intelligence (AI) to predict treatment effectiveness earlier using routine MRI scans, helping clinicians decide optimal timing for surgery.
What did we do? We analyzed data from 35 liver cancer patients treated with this combination therapy. An AI tool measured the tumor enhancement volume ratio (TEVR) on MRI scans and compared it with post-surgery pathology results. We focused on two questions: 1) Can TEVR reflect the proportion of surviving tumor cells? 2) Can TEVR predict postoperative recurrence risk?
What did we find? AI-measured TEVR strongly matched pathology findings: When TEVR ≤ 19.5%, tumors had ≤ 10% surviving cells (indicating major treatment response), with 87.9% accuracy in predicting liver recurrence. Patients meeting this threshold had 5 times longer recurrence-free survival time (81% lower risk). This AI method works faster than traditional approaches and avoids additional procedures.

Keywords: hepatocellular carcinoma, hepatic arterial infusion chemotherapy, HAIC, targeted therapy and immunotherapy, MRI, pathologic response, artificial intelligence, AI