Ultrasound-guided ablation of hepatocellular carcinoma: a review of its past, present, and future

Ultrasound (US)-guided ablation has evolved from early ethanol injection into a cornerstone curative strategy for hepatocellular carcinoma. This review traces the technological advancement of US guidance from early pioneering efforts to present standardized techniques and future innovations. It discusses how modern tools-fusion imaging, contrast-enhanced US, and artificial fluid techniques-overcome challenges in tumor visibility and accessibility, emphasizing technique optimization rather than energy modality selection. The review also explores future horizons, including artificial intelligence-driven planning, histotripsy, and immuno-ablation. Ultimately, the authors advocate for a philosophy of "optimized ablation," prioritizing technical mastery of evolving US technologies to maximize therapeutic efficacy and patient safety beyond simple expansion of treatment territory.