Is PET-CT (Positron Emission Tomography-Computed Tomography) recommended for a patient with grade 2 hepatocellular carcinoma (HCC) who has undergone a right hepatectomy, has normal alpha-fetoprotein (AFP) levels, normal liver function tests, and a good background liver?

PET-CT is NOT Recommended for Post-Hepatectomy Surveillance in Grade 2 HCC

The most recent and highest-quality guideline evidence explicitly recommends against using 18F-FDG and 18F-FCH PET/CT for tumor staging in hepatocellular carcinoma, and this applies to your post-hepatectomy surveillance scenario. 1

Guideline-Based Surveillance Protocol

Standard Imaging Approach

• Perform multiphase CT or MRI every 3 months for the first 24 months post-hepatectomy, as recurrence risk is 6.5 times higher in the first year compared to the second year 2
• After completing the initial 2-year intensive surveillance period, transition to surveillance every 6 months with the same imaging modalities 2
• Use a four-phase imaging protocol (non-contrast, arterial, portal venous, and delayed phases) 2
• Include chest imaging to detect extrahepatic metastases 2

Biomarker Monitoring

• Measure AFP at every surveillance visit (every 3 months for 2 years, then every 6 months), even though your patient currently has normal levels 1, 2
• Trending AFP is essential, as rising AFP even within the "normal" range may indicate recurrence before imaging changes become apparent 2
• Approximately 30-40% of HCCs are AFP-negative, so do not rely solely on AFP for surveillance decisions 2

Why PET-CT is Not Recommended

Guideline Position

The 2025 European Association for the Study of the Liver (EASL) guidelines provide a strong recommendation with strong consensus (96% agreement) against using 18F-FDG and 18F-FCH PET/CT for tumor staging 1

Limited Diagnostic Utility

• PET/CT has low utility for detecting HCC in general, as FDG uptake in HCC is variable 1
• The American College of Radiology notes that PET/CT is not an appropriate screening test for HCC 1
• Studies show low utility of FDG-PET/CT for detecting HCC even in high-risk scenarios like pre-transplant evaluation 1

Exception: When PET-CT May Have Limited Value

Specific Clinical Scenarios Only

While not recommended for routine surveillance, dual-tracer PET/CT (18F-FDG plus 18F-FCH) may be considered only in these specific situations:

• If AFP rises without corresponding findings on CT/MRI - FDG-PET showed 71% positivity in patients with unexplained AFP elevation 1
• If imaging findings are equivocal - dual-tracer PET/CT detected HCC in 45.1% of patients with unexplained AFP elevations 3
• For detecting extrahepatic disease not seen on conventional imaging - identified in 6% of HCC patients 1

However, even in these scenarios, the 2025 EASL guidelines maintain their strong recommendation against routine use 1

Prognostic Advantages in Your Case

Your patient has several favorable prognostic factors that support excellent outcomes with standard surveillance:

• Normal preoperative AFP is associated with better outcomes 2
• Normal liver function tests (Child-Pugh A) and good background liver without significant cirrhosis are favorable prognostic factors 2
• Grade 2 (moderately differentiated) HCC has better prognosis than poorly differentiated tumors 1

Cost-Effectiveness Considerations

• Multiphase CT or MRI are not recommended as first-line surveillance methods due to higher cost, but they are the standard for post-treatment surveillance 1
• While one research study suggested dual-tracer PET/CT provided cost savings of $495 per patient for metastatic screening 3, this has not been incorporated into major society guidelines
• The lack of guideline endorsement reflects insufficient evidence that PET/CT improves mortality or quality of life outcomes to justify routine use

Common Pitfalls to Avoid

• Do not order PET/CT as part of routine surveillance - stick to the evidence-based protocol of multiphase CT/MRI every 3 months 1, 2
• Do not dismiss rising AFP just because it remains in the "normal" range - trending is more important than absolute values 2
• Do not wait for symptoms before investigating - the goal is early detection when curative re-treatment remains feasible 2