Imaging biomarkers related to 18F-FDG PET/CT for predicting microvascular invasion in hepatocellular carcinoma: a systematic review and meta-analysis

Introduction This study, through a meta-analysis, aimed to assess the predictive performance of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) for microvascular invasion (MVI) in hepatocellular carcinoma (HCC). Methods Web of Science, Embase, PubMed, and Cochrane Library were comprehensively searched from database inception to January 13, 2026. EndNote 21was employed for literature screening and data extraction. Meta-analysis was carried out on the extracted data using Stata 15, MetaDisc 1.4, and MedCalc. Results In total, 21 studies were included, involving 2,023 patients with HCC, of whom 890 were MVI+ and 1,133 were MVI–. In univariable analyses, both tumor-to-normal liver uptake ratio (TLR) (odds ratio [OR] = 2.577, 95% confidence interval [CI]: 1.446–4.593, P = 0.001) and maximum standardized uptake value (SUVmax) (OR = 1.272, 95% CI: 1.036–1.561, P = 0.021) were significantly associated with an increased MVI risk. After multivariable adjustment, SUVmax retained independent predictive value (OR = 2.140, 95% CI: 1.244–3.681, P = 0.006), whereas the multivariable evidence for TLR was derived from a single study and required further validation. AUC values for SUVmax and radiomics score (Rad-score) were 0.819 (95% CI: 0.739–0.899) and 0.809 (95% CI: 0.762–0.857), respectively, with relatively balanced values for sensitivity, specificity, and negative likelihood ratio. Conclusion The available evidence supports SUVmax as one of the metabolic markers for preoperative MVI risk assessment in HCC, with Rad-score similar to SUVmax in diagnostic discrimination. The complementary value of the two markers was not demonstrated by this Meta-analysis, but rather derived from inferences proposed by external studies. Moreover, because the included radiomics studies did not report a pooled effect size for the combined model integrating SUVmax and Rad-score, a Meta-analysis targeting this model is currently not feasible. Therefore, the complementarity of SUVmax and Rad-score should be regarded as a hypothesis to be tested. In the future, multicenter, prospective radiomics studies with rigorous external validation are warranted to further explore a combined prediction model based on SUVmax and Rad-score. On this basis, an integrated assessment workflow should be gradually established, by which preoperative decisions are guided. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/ , identifier CRD420261289724.