Transarterial Radioembolization Research Articles

LI-RADS radiation-based treatment response algorithm for HCC: what to know and how to use it.

Locoregional treatments (LRT) continue to advance for hepatocellular carcinoma (HCC). Selective internal radiation therapy (SIRT) or transarterial radioembolization (TARE) with radioactive 90 Yttrium (Y90) microspheres is currently widely accepted, and external beam and stereotactic body radiation (EBRT/SBRT) are increasingly used as LRT1-5. Assessment of treatment response after these radiation-based therapies can be challenging, given that the adjacent liver also undergoes treatment related changes, inflammatory changes occur, and there is a variable time for response to develop. In 2017, the liver imaging reporting and data system (LI-RADS) workgroup initially developed a single algorithm for the imaging assessment of treatment response encompassing all types of locoregional therapies, the LI-RADS treatment response (LR-TR) algorithm. Recognizing that response and imaging patterns differ between radiation and non-radiation based therapies, the LR-TR working group recently updated the algorithm to reflect the unique characteristics of tumor response for therapies involving radiation. This article aims to elucidate the changes in the new version of the LI-RADS TR, with a guide for algorithm utilization and illustration of expected and unexpected findings post liver directed therapies for HCC.

Development and validation of an innovative administration system to facilitate controlled holmium-166 microsphere administration during TARE

BackgroundTo develop and validate a novel administration device for holmium-166 transarterial radioembolisation (TARE) with the purpose of facilitating controlled fractional microsphere administration for a more flexible and image-guided TARE procedure.MethodsA Controlled Administration Device (CAD) was developed using MR-conditional materials. The CAD contains a rotating syringe to keep the microspheres in suspension during administration. Different rotational speeds were tested ex vivo to optimise the homogeneity of microsphere fractions administered from the device. The technical performance, accuracy, and safety was validated in three patients in a clinical TARE setting by administering a standard clinical dose in 5 fractions (identifier: NCT05183776). MRI-based dosimetry was used to validate the homogeneity of the given fractions in vivo, and serious adverse device event ((S)A(D)E) reporting was performed to assess safety of the CAD.ResultsA rotational speed of 30 rpm resulted in the most homogeneous microsphere fractions with a relative mean deviation of 1.1% (range: -9.1-8.0%). The first and last fraction showed the largest deviation with a mean of -26% (std. 16%) and 7% (std. 13%). respectively. In the three patient cases the homogeneity of the microsphere fractions was confirmed given that MRI-based dosimetry showed near linear increase of mean absorbed target liver dose over the given fractions with R2 values of 0.98, 0.97 and 0.99. No (S)A(D)E’s could be contributed to the use of the CAD.ConclusionsThe newly developed CAD facilitates safe and accurate fractional microsphere administration during TARE, and can be used for multiple applications in the current and future workflows of TARE.

Combination makes strength: a narrative review of transarterial radioembolization plus immune checkpoint inhibitors for hepatocellular carcinoma.

Immune checkpoint inhibitors (ICIs) and transarterial radioembolization (TARE) are now regarded as promising and versatile therapies for hepatocellular carcinoma (HCC). Combining TARE and ICIs may offer synergistic antineoplastic effects by integrating local and systemic tumor control. This review critically discusses recent preclinical evidence supporting the TARE-ICI combination strategy, completed and ongoing clinical trials, and the challenges in identifying optimal target populations and treatment protocols. A comprehensive literature search was conducted in multiple electronic databases (PubMed, Scopus, and Web of Science) from January 1999 to January 2024. The first part of the search was directed at identifying concluded studies regarding the TARE-ICIs combination. The second part aimed at identifying ongoing clinical trials exploring the Clinicaltrials.gov database. The combination of TARE and ICIs is a promising strategy, supported by preclinical evidence of immune activation post-TARE and potential synergies with ICIs. Early-phase clinical trials have reported encouraging efficacy. However, significant heterogeneity exists among these studies, particularly concerning target populations and treatment schedules. The current evidence on TARE-ICI is favorable and promising in improving outcomes of patients with HCC. Further conclusive and higher levels of evidence are pending.

Comparative Analysis of Transradial and Transfemoral Approaches in Transarterial Radioembolization for Liver Tumors: A Systematic Review and Meta-Analysis.

Transarterial radioembolization (TARE) is a minimally invasive therapy combining embolization and radiation for cancer treatment. This meta-analysis compares radiation exposure, quality of life, and safety of the transradial (TRA) versus transfemoral (TFA) approaches in TARE for liver tumors. We searched PubMed, SCOPUS, Cochrane, EMBASE, and Web of Science for studies comparing TRA versus TFA in TARE for liver tumors. Our primary outcomes focused on various measures of patient radiation exposure, including procedure time, fluoroscopy time, air kerma, and dose-area product (DAP). For secondary outcomes, we evaluated safety parameters, such as overall pain experienced during the procedure, pain in the recovery room post-procedure, the incidence of adverse events, and the impact on quality of life. Study quality was assessed using Cochrane's ROB 2 tool for RCTs and the Newcastle-Ottawa scale for observational studies. Data analysis was conducted with REVMAN 5.4.1 software. Six studies, comprising one RCT and five cohort studies with 1,209 patients, underwent comprehensive analysis. The aggregated findings revealed a significant reduction in procedure duration associated with TRA (MD =- 6.30, 95% CI [- 9.88, - 2.73], P = 0.005). However, no statistically significant differences were found between TRA and TFA groups concerning fluoroscopy time, recovery time, air kerma, DAP, pain in the recovery room, overall pain during the procedure, quality of life measuring mental health and physical function or adverse events. TRA and TFA showed comparable results in TARE for liver tumors, but TRA offered a shorter procedure time. Further RCTs with larger samples are needed to confirm these findings. Future studies should assess long-term efficacy for a more complete evaluation.

Comparison of the therapeutic effects of transarterial radioembolization and tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis.

Comparison of the therapeutic effects of transarterial radioembolization and tyrosine kinase inhibitor in hepatocellular carcinoma with portal vein thrombosis.

Assessment of Y-90 Radioembolization Treatment Response for Hepatocellular Carcinoma Cases Using MRI Radiomics.

This study aimed to investigate the ability of radiomics features extracted from magnetic resonance imaging (MRI) images to differentiate between responders and non-responders for hepatocellular carcinoma (HCC) cases who received Y-90 transarterial radioembolization treatment. Thirty-six cases of HCC who underwent MRI scans after Y-90 radioembolization were included in this study. Tumors were segmented from MRI T2 images, and then 87 radiomic features were extracted through the LIFEx package software. Treatment response was determined 9 months after treatment through the modified response evaluation criteria in solid tumours (mRECIST). According to mRECIST, 28 cases were responders and 8 cases were non-responders. Two radiomics features, "Grey Level Size Zone Matrix (GLSZM)-Small Zone Emphasis" and "GLSZM-Normalized Zone Size Non-Uniformity", were the radiomics features that could predict treatment response with the area under curve (AUC)= 0.71, sensitivity= 0.93, and specificity= 0.62 for both features. Whereas the other 4 features (kurtosis, intensity histogram root mean square, neighbourhood gray-tone difference matrix strength, and GLSZM normalized grey level non-uniformity) have a relatively lower but acceptable discrimination ability range from AUC= 0.6 to 0.66. MRI radiomics analysis could be used to assess the treatment response for HCC cases treated with Y-90 radioembolization.

Is Liver Resection Still Required for Patients Who Have Predictive Factors for Complete Pathologic Necrosis after Downstaging Treatments of Locally Advanced Hepatocellular Carcinoma?

BackgroundLiver resection can induce complete remission after tumor downstaging in patients with locally advanced hepatocellular carcinoma. However, additional benefits of liver resection have not been investigated in patients expected to have complete pathological necrosis (CPN) following HCC downstaging. MethodsBetween 2002 and 2019, 999 patients with locally advanced HCC underwent concurrent chemoradiotherapy (CCRT) (n=800) or transarterial radioembolization (TARE) (n=199). Among these patients, excluding those who underwent liver transplantation, 94 who underwent liver resection (OP group) and 867 who did not undergo surgical treatment (non-OP group) were included in this study. CPN predictive factors in the OP group were analyzed using logistic regression analysis. Long-term outcomes were compared between patients with CPN (op-CPN) and those with CPN predictive factors in the non-OP group (nop-CPNPF). ResultsOf the 94 patients in the OP group, 38 (40.4%) had CPN (CCRT, n=72; TARE, n=22). In the multivariate analysis, CPN predictive factors were complete radiologic response and tumor marker responders (odds ratio [OR] 18.468, p=0.006; OR 3.698, p=0.045). Among the non-OP group, 21 patients were in the nop-CPNPF group. There was no difference in DFS between the nop-CPNPF and op-CPN groups (40.0 ± 18.3 vs. 60.0 ± 14.0 months, p=0.838). The OS of the op-CPN group was not higher than that of the nop-CPNPF group (5-year OS: 39.4% vs. 33.3%, p=0.328). ConclusionsThe nop-CPNPF group showed long-term outcomes similar to those of the op-CPN group, suggesting that liver resection may not provide additional benefits for long-term outcomes in patients with CPN-PF after HCC downstaging.

Locoregional Therapies for Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease.

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide with an average five-year survival rate in the US of 19.6%. With the advent of HBV and HCV treatment and prevention, along with the rising rates of obesity, nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome are set to overtake infectious causes as the most common cause of HCC. While surgical resection and transplantation can be curative when amenable, the disease is most commonly unresectable on presentation, and other treatment approaches are the mainstay of therapy. In these patients, locoregional therapies have evolved as a vital tool in both palliation for advanced disease and as a bridge to surgical resection and transplantation. In this review, we will be exploring the primary locoregional therapies for HCC in patients with NAFLD, including transarterial chemoembolization (TACE), bland transarterial embolization (TAE), transarterial radioembolization (TARE), and percutaneous ablation.

Transarterial radioembolization vs transarterial chemoembolization with drug-eluting beads for treating hepatocellular carcinoma: a cost-effectiveness analysis in Japanese healthcare system.

Transarterial radioembolization (TARE) is effective for unresectable hepatocellular carcinoma; however, it awaits approval in Japan. This study aimed to simulate the cost-effectiveness of TARE over chemoembolization when TARE is approved in Japan and identify the requirements for cost-effectiveness. A Markov model was constructed to analyze the costs and effectiveness associated with TARE and transarterial chemoembolization with drug-eluting beads (DEB-TACE) for 2-month cycles over 5years. In the primary analysis, the intention-to-treat survival data were used to calculate transition probabilities, whereas the ancillary analysis assessed the per-protocol survival data. DEB-TACE costs were calculated using the Japanese nationwide claims Diagnosis Procedure Combination database between April 2018 and March 2022, whereas TARE costs were estimated using database and international sources. The incremental cost-effectiveness ratio (ICER) was determined based on the payer's perspective and compared with the Japanese willingness-to-pay threshold of 5 million Japanese yen (JPY) (31,250 USD) per quality-adjusted life years (QALY). From the claims database, 6,986 patients with hepatocellular carcinoma who received DEB-TACE were identified. In the primary analysis, the ICER was 5,173,591 JPY (32,334 USD)/QALY, surpassing the Japanese willingness-to-pay threshold. However, the ancillary analysis showed a lower ICER of 4,156,533 JPY (25,978 USD)/QALY, falling below the threshold. The one-way deterministic sensitivity analysis identified progression-free survival associated with TARE and DEB-TACE, DEB-TACE costs, and radioactive microsphere reimbursement price as key ICER influencers. The primary analysis suggested that setting the reimbursement price of radioactive microspheres below 1.399 million JPY (8,744 USD), approximately 2.8% lower than the price in the United Kingdom, would place the ICER below the Japanese willingness-to-pay threshold. Under specific conditions, TARE can be a more cost-effective treatment than DEB-TACE. If the reimbursement price of radioactive microspheres is set approximately 2.8% lower than that in the United Kingdom, TARE could be cost-effective compared with DEB-TACE.

TACE vs. TARE for HCC ≥ 8cm: A propensity score analysis.

This study aimed to compare transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) as first-line treatments for unresectable HCC > 8cm. This retrospective study analyzed 129 HCC patients with tumor diameters greater than 8cm from January 2010 to December 2021, including 40 patients who received TARE, and 89 patients treated with TACE as primary treatment. Following Propensity Score Matching (PSM), 40 patients from each group were harmonized for baseline characteristics. Tumor responses were evaluated using mRECIST criteria, and survival outcomes were compared between treatment groups using Kaplan-Meier curves and the Log-rank test. There was no significant difference in the objective response rate (ORR) and disease control rate (DCR) at 3, 6, and 12 months between the two groups; ORR and DCR were 72.6%, 83.1% in TACE group vs. 72.5%. 87.5% in TARE group for best tumor response (p-values: 0.625 and 0.981, respectively). Overall survival (OS) and progression-free survival (PFS) between the two groups were comparable pre- and post-PSM. After PSM, the OS was 33.2 months (20.0-58.6) in TACE group and 38.1 months (13.8-98.1) in TARE group (p = 0.53), while PFS was 11.5 months (7.7-18.4) and 9.1 months (5.2-23.8) respectively. After PSM, post-embolization syndrome developed more in TACE group (100% vs. 75%, p = 0.002). Major adverse events were 72% in TACE group vs. 5% in TARE group (p < 0.001). TARE and TACE offer comparable efficacy in managing large HCC, with TARE providing a safer profile, suggesting its consideration as a preferable initial therapeutic approach for unresectable HCC patients with tumors larger than 8cm.

Transarterial Radioembolization Can Downstage Intermediate and Advanced Hepatocellular Carcinoma to Liver Transplantation.

Transarterial radioembolization (TARE) is an effective treatment to control tumor growth and improve survival in hepatocellular carcinoma (HCC). The role of TARE in downstaging patients to liver transplantation (LT) is unclear. The aim of this study was to investigate the downstaging efficacy of TARE for intermediate and advanced HCC. Intention-to-treat analysis with multistate modeling was performed. Patients moved through 5 health states: (1) from TARE to listing, (2) from TARE to death without listing, (3) from listing to LT, (4) from listing to death without LT, and (5) from transplant to death. Factors affecting the chance of death after TARE were considered to stratify outcomes. Two hundred fourteen patients underwent TARE. Of those, 43.9% had radiological response, 29.9% were listed, and 22.8% were transplanted. The probability of being alive without LT was 40.5% 1 y after TARE and 11.5% at 5 y. The chance of being listed was 9.4% at 1 y and 0.9% at 5 y. The probability of dying after TARE without LT was 38% at 1 y and 73% at 5 y. The overall survival of patients receiving LT was 61% at 5 y after transplant. Tumor beyond up-to-seven criteria, alfafetoprotein >400 ng/mL, and albumin-bilirubin ≥2 were associated with death. Three risk groups were associated with different response, chances of being listed, and receiving LT. Median survival was 3 y for low-risk, 1.9 y for intermediate-risk, and 9 mo for high-risk patients (P < 0.001). In intermediate and advanced HCC, TARE allows for a 44% chance of response, 30% downstaging, and 23% probability of permitting LT. Patient's and tumor's characteristics allow for risk stratification and predict survival from TARE.

Comprehensive Review of Future Liver Remnant (FLR) Assessment and Hypertrophy Techniques Before Major Hepatectomy: How to Assess and Manage the FLR.

The regenerative capacities of the liver and improvements in surgical techniques have expanded the possibilities of resectability. Liver resection is often the only curative treatment for primary and secondary malignancies, despite the risk of post-hepatectomy liver failure (PHLF). This serious complication (with a 50% mortality rate) can be avoided by better assessment of liver volume and function of the future liver remnant (FLR). The aim of this review was to understand and assess clinical, biological, and imaging predictors of PHLF risk, as well as the various hypertrophy techniques, to achieve an adequate FLR before hepatectomy. We reviewed the state of the art in liver regeneration and FLR hypertrophy techniques. The use of new biological scores (such as the aspartate aminotransferase/platelet ratio index + albumin-bilirubin [APRI+ALBI] score), concurrent utilization of 99mTc-mebrofenin scintigraphy (HBS), or dynamic hepatocyte contrast-enhanced MRI (DHCE-MRI) for liver volumetry helps predict the risk of PHLF. Besides portal vein embolization, there are other FLR optimization techniques that have their indications in case of risk of failure (e.g., associating liver partition and portal vein ligation for staged hepatectomy, liver venous deprivation) or in specific situations (transarterial radioembolization). There is a need to standardize volumetry and function measurement techniques, as well as FLR hypertrophy techniques, to limit the risk of PHLF.

Commentary on: Transarterial Radioembolization (TARE) Global Practice Patterns: An International Survey by the Cardiovascular and Interventional Radiology Society of Europe (CIRSE).

Commentary on: Transarterial Radioembolization (TARE) Global Practice Patterns: An International Survey by the Cardiovascular and Interventional Radiology Society of Europe (CIRSE).

Hepatopulmonary Shunt Ratio Verification Model for Transarterial Radioembolization.

The most important toxicity of transarterial radioembolization therapy applied in liver malignancies is radiation pneumonitis and fibrosis due to hepatopulmonary shunt of Yttrium-90 (90Y) microspheres. Currently, Technetium-99m macroaggregated albumin (99mTc-MAA) scintigraphic images are used to estimate lung shunt fraction (LSF) before treatment. The aim of this study was to create a phantom to calculate exact LFS rates according to 99mTc activities in the phantom and to compare these rates with LSF values calculated from scintigraphic images. A 3D-printed lung and liver phantom containing two liver tumors was developed from Polylactic Acid (PLA) material, which is similar to the normal-sized human body in terms of texture and density. Actual %LSFs were calculated by filling phantoms and tumors with 99mTc radionuclide. After the phantoms were placed in the water tank made of plexiglass material, planar, SPECT, and SPECT/CT images were obtained. The actual LSF ratio calculated from the activity amounts filled into the phantom was used for the verification of the quantification of scintigraphic images and the results obtained by the Simplicity90YTM method. In our experimental model, LSFs calculated from 99mTc activities filled into the lungs, normal liver, small tumor, and large tumor were found to be 0%, 6.2%, 10.8%, and 16.9%. According to these actual LSF values, LSF values were calculated from planar, SPECT/CT (without attenuation correction), and SPECT/CT (with both attenuation and scatter correction) scintigraphic images of the phantom. In each scintigraphy, doses were calculated for lung, small tumor, large tumor, normal liver, and Simplicity90YTM. The doses calculated from planar and SPECT/CT (NoAC+NoSC) images were found to be higher than the actual doses. The doses calculated from SPECT/CT (with AC+with SC) images and Simplicity90YTM were found to be closer to the real dose values. LSF is critical in dosimetry calculations of 90Y microsphere therapy. The newly introduced hepatopulmonary shunt phantom in this study is suitable for LSF verification for all models/brands of SPECT and SPECT/CT devices.

Invited Commentary on "Single-Session Ablative Transarterial Radioembolization for Patients With Hepatocellular Carcinoma to Streamline Care: An Initial Experience".

Invited Commentary on "Single-Session Ablative Transarterial Radioembolization for Patients With Hepatocellular Carcinoma to Streamline Care: An Initial Experience".

Survival After Transarterial Radioembolization in Patients with Unresectable Intrahepatic Cholangiocarcinoma: An Updated Meta-analysis and Meta-regression

PurposeTransarterial radioembolization (TARE) has emerged as a promising therapeutic approach for unresectable intrahepatic cholangiocarcinoma (ICCA). We updated our previous meta-analysis with meta-regression to explore the efficacy of TARE in the context of ICCA.MethodsWe searched PubMed and Scopus for studies published up to September 1, 2023. The primary outcome was overall survival. Secondary outcomes were tumor overall response rate, severe adverse events, and downstaging to surgery. Meta-analysis employed a random-effects model, and meta-regression was utilized to explore sources of heterogeneity.ResultsWe included 27 studies, involving 1365 patients. Pooled survival estimates at 1, 2, and 3 years were 52.6%, 27%, and 16.8%, respectively. Meta-regression revealed that the proportion of patients naïve to treatment was the only pre-TARE predictor of survival (1-, 2-, and 3-year survival of 70%, 45%, and 36% for treatment-naïve patients, mean survival 19.7 months vs. 44%, 18%, and 7% for non-naïve patients, mean survival 12.2 months). Overall response according to RECIST 1.1 and mRECIST was 19.6% and 67%, respectively. Effective downstaging to surgery was possible in varying rates (3–54%); the mean survival in these patients was 34.8 months (1-, 2-, and 3-year survival of 100%, 87%, and 64%). About 45.7% of patients experienced adverse events, but only 5.9% were severe.ConclusionsOur study benchmarked the survival rates of patients undergoing TARE for unresectable ICCA and showed that this is a valid option in these patients, especially if naïve to previous treatments. Downstaging to surgery is feasible in selected patients with promising results.Graphical

Angiographic Aspects of Transarterial Radioembolization: A Comparison of Technical Options to Avoid Extrahepatic Microsphere Depositions.

The influence of the interventional treatment approach for transarterial radioembolization (TARE) on the incidence of extrahepatic microsphere depositions and to angiographic complications was evaluated. In total, 398 TARE cycles were analyzed. Interventional treatment approaches were classified as single treatment position (TP) with interventional occlusion (IO), multiple TPs without IO, and multiple TPs with IO. Correlations with extrahepatic microsphere depositions, angiographic complications, and periprocedural clinical events were performed. Alternative treatment strategies were evaluated. Applications from multiple TPs could have ensured the safe application of microspheres in 48.2% of cases that were originally performed from a single TP after IO. Extrahepatic microsphere accumulations were detected after 5.2%, 5.3%, and 1.5% of TARE procedures from a single TP without IO, a single TP with IO, and multiple TPs without IO, respectively. Applications from multiple TPs did not increase angiographic complications. During the 30-day follow-up, nausea/vomiting and upper abdominal discomfort were observed more frequently in the group with IO than in the group without IO (7.9%/4.6% and 9.2%/5.9%, respectively). In many TARE procedures, the same target liver can be treated from multiple TPs instead of a single TP, reducing the need for the interventional occlusion of aberrant arteries and potential extrahepatic microsphere depositions.

Arterial hypoperfusion as a negative predictive marker for primary hepatic malignancies treated with Y-90 glass microsphere transarterial radioembolization.

Radioembolization with yttrium-90 (Y-90) is utilized to treat primary liver malignancies. The efficacy of this intra-arterial therapy in arterially hypoperfused tumors is not known. We reviewed data of patients with primary liver tumors treated with Y-90 prescription doses of at least 150 Gy. Baseline patient characteristics, treatment history, imaging-based tumor response assessments, and clinical outcome metrics were recorded. Tumors were classified as arterially hyperperfused versus hypoperfused on post-TARE Y-90 SPECT/CTs or pre-TARE hepatic perfusion SPECT/CTs. Perfusion status was correlated with tumor response assessments and clinical outcomes. Cox proportional hazards models were utilized to compare survival and progression-free survival. Inverse probability weighting was utilized to account for clinical factors and adjusted multivariable proportional hazards analyses to examine the relationship of quantitative perfusion and cancer outcomes. Of 400 Y-90 treatments, 88 patients received a prescribed dose of at least 150 Gy and had pre- or post-treatment SPECT/CT images. 11 and 77 patients had arterially hypoperfused and hyperperfused lesions, respectively. On dedicated liver MRI or CT at 3 months after Y-90, the complete response rates were 5.6% and 16.5% in the hypoperfused and hyperperfused cohort, respectively (P = 0.60). When controlling for various clinical features, including tumor histology, patients with arterially hypoperfused tumors had significantly shorter progression-free survival (HR 1.87, 95% CI - 1.03 - 3.37, P = 0.039) and greater elsewhere liver (HR 3.36, 95% CI = 1.23 - 9.20, P = 0.019) and distant failure (HR 7.64 (2.71 - 21.54, P < 0.001). In inverse probability weighted analysis, patients with arterially hypoperfused tumors had worse overall survival (P = 0.032). In the quantitative analysis, lower levels of lesion perfusion were also associated with worse clinical outcomes, again controlling for tumor histology. Compared to arterially hyperperfused tumors, hypoperfused primary liver tumors treated with Y-90 may have worse clinical outcomes.

Radioembolization of HCC and secondary hepatic tumors: a comprehensive review.

Transarterial radioembolization (TARE), also called Selective Internal Radiation Therapy (SIRT), has emerged as an effective locoregional therapy for primary and secondary hepatic tumors, utilizing yttrium-90 (Y90) microspheres and other agents such as holmium-166 and rhenium-188. TARE has various applications in the management of HCC across different BCLC stages. Radiation segmentectomy, which involves administering high doses of Y90 (>190 Gy), can be both curative and ablative, achieving complete necrosis of the tumor. In contrast, radiation lobectomy involves administering a lower dose of Y90 (80-120 Gy) as a neoadjuvant treatment modality to improve local control and induce future liver remnant (FLR) hypertrophy in patients who are planned to undergo surgery but have insufficient FLR. Modified radiation lobectomy combines both techniques and offers several advantages over portal vein embolization (PVE). Y90 is also used in downstaging HCC patients outside liver transplantation criteria, as well as bridging those awaiting liver transplantation (LT). Multiple studies and combined analyses were described to highlight the outcomes of TARE and compare it with other treatment modalities, including TACE and sorafenib. Additionally, the review delves into the efficacy and safety of radioembolization in managing metastatic colorectal cancer and other metastatic tumors to the liver. Recent studies have emphasized the role of personalized dosimetry for improved outcomes, and thus we described the different methods used for this purpose. Pretherapy imaging, estimating lung shunt, selection of therapeutic radionuclides, adverse effects, and cost-effectiveness were all discussed as well.

Yttrium-90 Induces an Effector Memory Response with Neoantigen Clonotype Expansion: Implications for Immunotherapy.

90Y can safely treat HCC; however, it causes transient lymphopenia. In this article, 90Y stimulates a peripheral effector memory response independent of initial treatment response. TCR sequencing revealed that polyclonal profiles in patients without an OR to treatment were associated with rapid progression rates 6 months after 90Y.