{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T03:09:37Z","timestamp":1773889777516,"version":"3.50.1"},"reference-count":63,"publisher":"MDPI AG","issue":"24","license":[{"start":{"date-parts":[[2025,12,18]],"date-time":"2025-12-18T00:00:00Z","timestamp":1766016000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Conventional ultrasound (US) has long been central to hepatocellular carcinoma (HCC) surveillance in cirrhotic patients, due to its low cost, wide availability, non-invasiveness, and adequate sensitivity for detecting small nodules. However, its specificity in distinguishing HCC from other lesions is limited. Contrast-enhanced ultrasound (CEUS) has significantly improved the characterization of nodules first identified on conventional US. Yet, when CEUS is performed using sulfur hexafluoride (SonoVue)\u2014the only contrast agent available in Western countries\u2014assessment remains restricted to a single nodule per examination, and enhanced CT or MRI is still required for full characterization and staging. In clinical settings, such as hepatology, internal medicine, infectious diseases, and surgery, CEUS offers the advantage of immediate availability, enabling rapid characterization of suspicious nodules in cirrhotic livers and facilitating timely therapeutic decisions. Although the introduction of direct-acting antivirals (DAAs) has substantially reduced HCV-related HCC, HCC incidence is increasingly driven by metabolic dysfunction-associated steatohepatitis (MASH). Evidence on surveillance strategies for MASH patients remains limited, and current EASL guidelines recommend monitoring only patients with &gt;F2 fibrosis. Additionally, the effectiveness of US in obese or diabetic\/obese populations is under ongoing investigation; abbreviated non-contrast MRI has been proposed as an alternative surveillance tool, but its adoption would entail significant economic implications for healthcare systems. HCC arising from MASH\u2014sometimes even without cirrhosis\u2014exhibits different sonographic and pathological features. Instead of small, hypoechoic nodules, typically seen in HCV-related cirrhosis, clinicians increasingly encounter larger or multiple lesions, often accompanied by macrovascular invasion, limiting access to curative treatments. Furthermore, typical CEUS LI-RADS patterns are less frequently observed. This review summarizes the evolving US findings in the era of MASH-related HCC and underscores the continued importance of US as the primary imaging tool in routine clinical practice.<\/jats:p>","DOI":"10.3390\/cancers17244037","type":"journal-article","created":{"date-parts":[[2025,12,18]],"date-time":"2025-12-18T16:42:05Z","timestamp":1766076125000},"page":"4037","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["HCC in the Era of Emerging MASH: The Role of Ultrasound in Surveillance and New Sonographic Features in Diagnosis"],"prefix":"10.3390","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4606-7780","authenticated-orcid":false,"given":"Antonio","family":"Giorgio","sequence":"first","affiliation":[{"name":"Liver Unit, Athena Clinical Center, Piedimonte, 81016 Caserta, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1675-1696","authenticated-orcid":false,"given":"Massimo","family":"De Luca","sequence":"additional","affiliation":[{"name":"Liver Unit, Cardarelli Hospital, 80131 Naples, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6968-4947","authenticated-orcid":false,"given":"Anna","family":"Lombardi","sequence":"additional","affiliation":[{"name":"Department of Translational Medical Sciences, Federico II University Hospital, 80131 Naples, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9942-0766","authenticated-orcid":false,"given":"Emanuela","family":"Cirac\u00ec","sequence":"additional","affiliation":[{"name":"Ostuni Civic Hospital, Internal Medicine, Ostuni, 72017 Brindisi, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-1129-5111","authenticated-orcid":false,"given":"Valeria Cosima","family":"Rollo","sequence":"additional","affiliation":[{"name":"Ostuni Civic Hospital, Internal Medicine, Ostuni, 72017 Brindisi, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3620-3275","authenticated-orcid":false,"given":"Antonella","family":"Di Sarno","sequence":"additional","affiliation":[{"name":"Department of Endocrinology, Diabetology, Andrology and Clinical Nutrition, Federico II University Hospital, 80131 Naples, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6081-9945","authenticated-orcid":false,"given":"Luca","family":"Montesarchio","sequence":"additional","affiliation":[{"name":"General Surgery with Minimally Invasive Oncology and High Specialization in Esophageal-Gastric Procedures, Cardarelli Hospital, 80131 Naples, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2179-5992","authenticated-orcid":false,"given":"Giuseppe","family":"Stella","sequence":"additional","affiliation":[{"name":"Unit\u00e0 Operativa Semplice Dipartimentale Spina Bifida e Uropatie Congenite, Fondazione Policlinico Universitario \u201cA. Gemelli\u201d IRCCS, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7448-8710","authenticated-orcid":false,"given":"Valentina","family":"Giorgio","sequence":"additional","affiliation":[{"name":"Unit\u00e0 Operativa Semplice Dipartimentale Spina Bifida e Uropatie Congenite, Fondazione Policlinico Universitario \u201cA. Gemelli\u201d IRCCS, Universit\u00e0 Cattolica del Sacro Cuore, 00168 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,18]]},"reference":[{"key":"ref_1","first-page":"229","article-title":"Global cancer statistics 2022: GLO-BOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries","volume":"74","author":"Bray","year":"2024","journal-title":"CA Cancer J Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.soc.2014.09.001","article-title":"Epidemiology of hepatocellular carcinoma","volume":"24","author":"Lafaro","year":"2015","journal-title":"Surg. Oncol. Clin. N. Am."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Leyh, C., Coombes, J.D., Schmidt, H.H., Canbay, A., Manka, P.P., and Best, J. (2024). MASLD-Related HCC-Update on Pathogenesis and Current Treatment Options. J. Pers. 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