Purpose: This study evaluates the diagnostic performance of quantitative diffusion-weighted imaging (DWI), including both conventional and intravoxel incoherent motion (IVIM)-derived parameters, in differentiating hepatocellular carcinoma (HCC) from intrahepatic cholangiocarcinoma (ICC).

Method: A systematic review and meta-analysis were conducted following a pre-registered protocol ( https://osf.io/9yhrg ). Relevant studies were identified through PubMed, Web of Science, Cochrane Library, and Embase up to March 8, 2025. Quantitative DWI parameters, including apparent diffusion coefficient (ADC), pure diffusion coefficient (D), pseudo-diffusion coefficient (pseudo-D), and perfusion fraction (f), were compared between HCC and ICC using a random-effects model. Sensitivity analysis and publication bias tests were performed.

Results: Twenty-one studies encompassing 1109 HCC and 838 ICC lesions were included. Pooled ADC values did not differ significantly between HCC (1.10, 95% CI = 1.03 to 1.17) and ICC (1.16, 95% CI = 1.06 to 1.25) groups (p = 0.156). In contrast, D showed significant differentiation between HCC (0.89, 95% CI = 0.77 to 1.02) and ICC (1.04, 95% CI = 0.93 to 1.16), with p < 0.001. Moreover, the pseudo-D parameter demonstrated comparable values in ICC (53.3; 95% CI, 22.47-84.13) and HCC (49.35; 95% CI, 23.28-75.41) lesions (p = 0.912). Finally, the f parameter revealed significantly (p = 0.022) lower values for ICC (19.21, 95% CI = 12.98 to 25.44) compared to HCC (23.78, 95% CI = 14.76 to 32.8). For each parameter, we calculated pooled mean differences, standardized mean differences, percentage differences, sensitivity, specificity, and area under the curve.

Conclusion: While ADC retains clinical utility due to widespread availability, this meta-analysis establishes D as a superior biomarker over ADC for distinguishing ICC from HCC focal liver lesions. These findings support the integration of non-Gaussian DWI techniques in clinical practice for improved tumor characterization