Search Results (58)

Background: Hepatocellular carcinoma (HCC) continues to pose a significant global health burden, especially when diagnosed at a symptomatic or advanced stage. In such cases, prompt and well-coordinated treatment plays a key role in improving patient outcomes. This study explores the effect of introducing the Order–Map–Treat (OMT) protocol, designed to streamline clinical decision-making and minimize treatment delays, on the survival of HCC patients undergoing transarterial radioembolization (TARE). Methods: This retrospective cohort included 185 HCC patients (69.2% males), of which 88 (47.6%) underwent TARE before the implementation of the OMT system in 2021 (Group 1) and 97 (52.4%) afterwards (Group 2). The mean age of the entire cohort was 71 ± 12 years. A significantly larger number of patients treated before 2021 had an ECOG score of 0 (p < 0.001). Group 1 had significantly more multifocal disease, while group 2 had more unilobar involvement. More patients with PVTT3 and PVTT4 were treated after the implementation of the OMT protocol (p = 0.009). Results: The OMT protocol significantly reduced the median decision to treatment period (p-value ≤ 0.001) from 37 days to 15 days and mapping to the TARE period from 21 days to 1 day, shortening the total days needed for treatment by 32 days approximately. The median survival from TARE was 1.4 years (95% CI: 1.1 to 1.6) for the entire cohort. When stratified by treatment period, patients treated before OMT had a median survival of 1.5 years (95% CI: 1.2 to 1.9), while those treated after OMT implementation had a median survival of 1.2 years (95% CI: 0.9 to 1.6). The difference was not statistically significant (p = 0.415). Conclusions: While there were no significant survival benefits, the OMT protocol offers more efficient HCC management by minimizing delays in treatment, potentially improving patient experience and cost effectiveness. Full article

Background/Objectives: Over the past few years, high-dose radioembolization (≥150 Gy) has become widely adopted for the treatment of primary liver cancer, while evidence for its application in hepatic metastases is still limited. The aim of this study was to evaluate the safety and efficacy of high-dose transarterial radioembolization (TARE) in patients with hepatic metastases using resin Yttrium-90 (⁹⁰Y) microspheres. Methods: In this retrospective analysis, patients who were treated with high-dose TARE for hepatic metastases with ⁹⁰Y resin microspheres between May 2019 and April 2025 were included. The primary outcomes were treatment efficacy and toxicity assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events v5.0. Treatment efficacy was evaluated based on radiological response according to Response Evaluation Criteria in Solid Tumors version 1.1, time to progression and overall survival (OS). Secondary outcomes included ⁹⁰Y PET/CT post-treatment voxel-based local deposition model dosimetry and its relations to response. Results: A total of 15 patients were included, with hepatic metastases originating from colorectal cancer (n = 11, 73.3%), neuroendocrine tumor (n = 3, 20%) and breast cancer (n = 1, 6.7%). Seven patients (47.7%) had undergone one or multiple prior loco(regional) liver treatments and 13 (86.7%) patients had prior systemic therapy. The median mean tumor absorbed dose was 160.7 Gy (IQR 127.6–245.0 Gy), and the median normal liver parenchyma dose was 40.3 Gy (IQR 21.7–52.3 Gy). Disease control was achieved in all patients, with partial response in 10 patients (66.7%) and stable disease in 5 patients (33.3%) after 3 months. The median OS was 26.5 months (95% CI 24.5 months to no estimate). Two patients (13.3%) experienced grade 3 laboratory toxicity. No grade 4 or 5 toxicities were observed. Conclusions: High-dose TARE with ⁹⁰Y resin microspheres resulted in a high disease control rate and demonstrated a favorable safety profile, even in this heavily pretreated cohort. Full article

Cancer is a leading cause of cancer-related death. Liver metastases develop in over one-third of patients and are associated with worse prognosis. The evolution in the field of interventional oncology/radiology over the past two decades has expanded image-guided locoregional therapies for colorectal liver metastases (CLM). Historically, hepatic resection was considered the only possible cure for selected patients with CLM. Current evidence supports thermal ablation (TA) as another locally curative treatment modality for small CLM that can be ablated with adequate margins. Other non-thermal ablative treatment options include Yttrium-90 (⁹⁰Y) radiation segmentectomy (RS), irreversible electroporation (IRE), and histotripsy, with an evolving role in the treatment of CLM. More extensive disease that is not amenable to resection or ablation can be treated with intra-arterial therapies (⁹⁰Y trans-arterial radioembolization (TARE) and trans-arterial chemoembolization (TACE)). This comprehensive review describes the evolution of interventional oncology treatments for CLM and examines the appropriate indications for each treatment modality. Full article

Quantitative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is emerging as a valuable tool for assessing tumor and parenchymal perfusion in the liver, playing a developing role in locoregional therapies (LRTs) for hepatocellular carcinoma (HCC). This review explores the conceptual underpinnings and early investigational stages of DCE-MRI for LRTs, including thermal ablation, transarterial chemoembolization (TACE), and transarterial radioembolization (TARE). Preclinical and early-phase studies suggest that DCE-MRI may offer valuable insights into HCC tumor microvasculature, treatment response, and therapy planning. In thermal ablation therapies, DCE-MRI provides a quantitative measurement of tumor microvasculature and perfusion, which can guide more effective energy delivery and estimation of ablation margins. For TACE, DCE-MRI parameters are proving their potential to describe treatment efficacy and predict recurrence, especially when combined with adjuvant therapies. In ⁹⁰Y TARE, DCE-MRI shows promise for refining dosimetry planning by mapping tumor blood flow to improve microsphere distribution. However, despite these promising applications, there remains a profound gap between early investigational studies and clinical translation. Current quantitative DCE-MRI research is largely confined to phantom models and initial feasibility assessments, with robust retrospective data notably lacking and prospective clinical trials yet to be initiated. With continued development, DCE-MRI has the potential to personalize LRT treatment approaches and serve as an important tool to enhance patient outcomes for HCC. Full article

Background: Transarterial radioembolization (TARE) with Yttrium-90 microspheres is an established therapy for unresectable hepatocellular carcinoma (HCC). However, its clinical efficacy compared to transarterial chemoembolization (TACE) remains unclear. Methods: We retrospectively reviewed 279 consecutive patients undergoing TARE (n = 104) or TACE (n = 175) at four tertiary centers. Patients with metastatic disease, locally advanced HCC, or Child–Pugh (CP) C were excluded. Data on treatment, adverse events, survival outcomes (median overall survival [mOS], and objective response rates [by modified Response Evaluation Criteria in Solid Tumors; mRECIST]) were collected. Results: The median follow-up of the cohort was 27 months (IQR 13–50), the mean age was 67.6 ± 10.1 years, and 207 (74.2%) were male. The cohort was balanced in age, performance status, CP class, and HCC etiology. Maximum tumor diameter was significantly larger in the TARE cohort compared to the TACE cohort (4.4 vs. 3.1 cm, p < 0.001), including within the BCLC 0/A (4.2 vs. 2.7 cm, p = 0.001) and BCLC B (5.0 vs. 4.0 cm, p = 0.049) subgroups. The mOS was longer with TACE (37 vs. 22 months; hazard ratio [HR] 1.65, 95% CI: 1.19–2.29, p = 0.002). In BCLC 0/A patients, TACE yielded longer mOS (60 vs. 25 months; HR 2.35, 95% CI: 1.17–4.69; p = 0.016). In BCLC B, mOS was longer with TACE (32 vs. 20 months), but was not statistically significant (HR 1.39, 95% CI: 0.96–2.03, p = 0.080). In BCLC 0/A, complete response rates were higher with TACE (43.2% vs. 34.3%, p = 0.012). Hepatic decompensation was more frequent with TARE- (26.0%) than with TACE-treated patients (13.7%, p = 0.010). Conclusions: TACE demonstrated superior survival outcomes over TARE, particularly in early-stage disease. These results advocate for a more nuanced selection of embolization therapies in these patients. Full article

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer deaths worldwide. Despite the high incidence of HCC, mortality remains high, with an estimated 5-year survival rate of less than 20%. Surgical resection represents a potential curative treatment for HCC; however, less than 20% of patients with HCC are candidates for surgical resection. In patients with unresectable HCC, Yttrium-90 (Y90) transarterial radioembolization (TARE) has emerged as an innovative treatment option. This locoregional therapy delivers high doses of radiation directly to liver tumors via intra-arterial injection, allowing for the targeted destruction of malignant cells while sparing surrounding healthy tissue. In this review, we will explore the latest advances in Y90 TARE for the treatment of HCC, focusing on key developments such as the following: (1) improvements in radiation lobectomy and segmentectomy techniques, (2) the introduction of personalized dosimetry, (3) the integration of combination therapies, (4) the use of imageable microspheres, (5) pressure-enabled Y90 delivery systems, and (6) the application of Y90 surrogates. Full article

Background/Objectives: Studies have indicated that forgoing lung shunt fraction measurement in select patients undergoing Yttrium 90 (Y90) transarterial radioembolization (TARE) may be safe without sacrificing efficacy. This study evaluated the safety and efficacy of a streamlined treatment in patients with small hepatocellular carcinoma (HCC) receiving resin-based TARE. Methods: Patients who received single-session Y90 TARE between September 2023 and May 2024 were retrospectively evaluated. Treatment response was evaluated at the 3-month follow-up using the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. Adverse events (AEs) ≥ Grade 3 were recorded post-procedurally at 3 months. The time from the interventional radiology clinic visit to the procedure date was compared to patients receiving the conventional TARE treatment. Results: Ten consecutive patients were treated with 12 treatments. Each treatment targeted an isolated lesion with median size of 2.5 cm (IQR: 2.1, 2.9). Two patients received two treatments (one for treatment of a separate lesion and the other for the initial incomplete targeting of the tumor). The median delivered tumor dose was 377.7 Gy (IQR: 246.5, 570.1). No patients developed ≥ Grade 3 AEs post-TARE. Complete response was achieved in 11/12 patients (92%). The conventional cohort consisted of 60 patients, all OPTN T2 treated with radiation segmentectomy with glass microspheres. Patients undergoing SSMT had a median time from clinic visit to treatment of 26.5 days (IQR: 15.3, 39) vs. 61 days (IQR: 48, 88.8) in the conventional TARE group (p < 0.001). Conclusions: Streamlined single-session resin-based Y90-TARE in patients with OPTN T2 stage HCC is feasible, efficacious, safe, and associated with reduced time to treatment. Full article

Background: The present study aims to investigate the superiority of TARE-Y90 in the treatment of liver metastases from colorectal cancer in comparison to DEBIRI and perform a parallel resource consumption study to demonstrate a possible favorable cost-effectiveness balance. Methods: The number of subjects included in this study was 46 for TARE-Y90 and 56 in the DEBIRI group. The variables of interest in this study were collected for all selected subjects. Time-to-endpoint outcomes (overall survival, time to progression and time to extra-hepatic progression) were calculated by Kaplan–Meier analysis, reported as medians with 95% confidence intervals and compared between groups by log-rank testing. Values for median time-to-event and 95% confidence intervals were calculated using bootstrapping. Results: Categorization into overall response (OR) and no overall response (NOR) revealed a higher percentage of overall responses in the DEBIRI group (52%) compared to TARE-Y90 (24%). The numerical differences observed in certain response categories did not reach statistical significance, indicating a comparable overall response to treatment between the two cohorts based on the m-RECIST criteria. Median overall survival for the TARE-Y90 cohort was 11.3 (95% CI 10.9–18.6) months and 15.8 (95% CI 14.8–22.7) months for the DEBIRI cohort. Log-rank testing showed no statistically significant differences (p = 0.53). Median time to hepatic disease progression for the TARE-Y90 cohort was 3.5 (95% CI 3.4–8.1) months and 3.8 (95% CI 3.7–11.1) months for the DEBIRI cohort. Log-rank testing showed no statistically significant differences (p = 0.82). An important result of the resource utilization analysis is that TARE-Y90 patients had 1.33 treatments on average per patient, while DEBIRI patients had 3.16 treatments per patient. TARE-Y90 patients also needed fewer days of hospitalization than those in the DEBIRI group. The consequence is that the overall use of resources was higher for DEBIRI in comparison to TARE-Y90. Conclusions: Our analysis of the TARE-Y90 and DEBIRI treatments for CRC liver metastases contributes valuable insights into their comparative effectiveness, revealing no significant differences in radiological responses and overall survival. TARE-Y90 showed higher resource utilization, and its potential advantages in patient comfort and average resource consumption per patient warrant consideration. Full article

In same-day radioembolization, 99mTc-MAA SPECT/CT, 90Y radioembolization, and post-treatment 90Y SPECT/CT procedures are conducted on the same-day, resulting in a dual-isotope environment of 90Y and 99mTc during post-treatment imaging. This study aimed to quantify the impact of 99mTc on 90Y bremsstrahlung-SPECT/CT image quality and to establish an optimised imaging protocol for both clinical practice, and with advanced reconstruction techniques. Utilising a NEMA IQ phantom, contrast recovery coefficients (CRCs) were measured to evaluate the 90Y image quality degradation caused by 99mTc. SPECT/CT scans of 90Y-only and 90Y with varying amounts of 99mTc were conducted using a standard protocol (90–120 keV energy window, high-energy collimator) and various dual-isotope protocols. The standard protocol resulted in a marked CRC reduction, with the largest sphere’s CRC decreasing from 0.21 (90Y-only) to 0.05 when 99mTc activity was 5% of 90Y. For an optimised protocol (160–200 keV energy window, high-energy collimator) CRC values were 0.16 for 90Y-only and 0.15 for 90Y+99mTc. The highest CRC values were achieved with an advanced Monte Carlo-based reconstruction, showing 0.58 for 90Y-only and 0.46 for 90Y+99mTc. Image quality degradation was noted in dual-isotope settings even when using an optimised protocol. Advanced reconstruction techniques markedly improved post-treatment image quality. Full article

This study compares various methodologies for lung dosimetry in radioembolization using Monte Carlo (MC) simulations. A voxelized anthropomorphic phantom, created from a real patient’s CT scan, preserved the actual density distribution of the lungs. Lung dosimetry was evaluated for five lung-shunt (LS) cases using traditional methods: the mono-compartmental organ-level approach (MIRD), local energy deposition (LED), and convolution with voxel S-values, either with local density corrections (SVOX_L) or without (SVOX_ST). Additionally, a novel voxel S-value (VSV) kernel for lung tissue with an ICRU density of $0.296\mathrm{g}/\mathrm{c}{\mathrm{m}}^3$ was developed. Calculations were performed using either the ICRU lung density (Lung_296), the average lung density of the phantom (Lung_221), or the local density (Lung_L). The comparison revealed significant underestimations in the mean absorbed dose (AD) for the classical approaches: approximately −$40\%$ for MIRD, −$27\%$ for LED, −$28\%$ for SVOX_L, and −$88\%$ for SVOX_ST. Similarly, calculations with the lung VSV kernel showed underestimations of about −$62\%$ for Lung_296, −$50\%$ for Lung_221, and −$35\%$ for Lung_L. Given the high heterogeneity of lung tissue, traditional dosimetric methods fail to provide accurate estimates of the mean AD for the lungs. Therefore, MC dosimetry based on patient images is recommended as the preferred method for precise assessment of lung AD during radioembolization. Full article

The aim of this study was to evaluate outcomes of transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) in patients previously treated with transarterial embolization (TAE). In this retrospective study, all HCC patients who received TARE from 1/2012 to 12/2022 for treatment of residual or recurrent disease after TAE were identified. Overall survival (OS) was estimated using the Kaplan–Meier method. Univariate Cox regression was performed to determine significant predictors of OS after TARE. Twenty-one patients (median age 73.4 years, 18 male, 3 female) were included. Median dose to the perfused liver volume was 121 Gy (112–444, range), and 18/21 (85.7%) patients received 112–140 Gy. Median OS from time of HCC diagnosis was 32.9 months (19.4–61.4, 95% CI). Median OS after first TAE was 29.3 months (15.3–58.9, 95% CI). Median OS after first TARE was 10.6 months (6.8–27.0, 95% CI). ECOG performance status of 0 (p = 0.038), index tumor diameter < 4 cm (p = 0.022), and hepatic tumor burden < 25% (p = 0.018) were significant predictors of longer OS after TARE. TARE may provide a survival benefit for appropriately selected patients with HCC who have been previously treated with TAE. Full article

Background: Introduced in the latest BCLC 2022, endovascular trans-arterial radioembolization (TARE) has an important role in the treatment of unresectable hepatocellular carcinoma (HCC) as a “bridge” or “downstaging” of disease. The evolution of TARE technology allows a more flexible and personalized target treatment, based on the anatomy and vascular characteristics of each HCC. The flex-dose delivery program is part of this perspective, which allows us to adjust the dose and its radio-embolizing power in relation to the size and type of cancer and to split the therapeutic dose of Y90 in different injections (split-bolus). Methods: From January 2020 to January 2022, we enrolled 19 patients affected by unresectable HCC and candidates for TARE treatment. Thirteen patients completed the treatment following the flex-dose delivery program. Response to treatment was assessed using the mRECIST criteria with CT performed 6 and 9 months after treatment. Two patients did not complete the radiological follow-up and were not included in this retrospective study. The final cohort of this study counts eleven patients. Results: According to mRECIST criteria, six months of follow-up were reported: five cases of complete response (CR, 45.4% of cases), four cases of partial response (PR, 36.4%), and two cases of progression disease (PD, 18.2%). Nine months follow-up reported five cases of complete response (CR, 45.4%), two cases of partial response (PR, 18.2%), and four cases of progression disease (PD, 36.4%). No intra and post-operative complications were described. The average absorbed doses to the hepatic lesion and to the healthy liver tissue were 319 Gy (range 133–447 Gy) and 9.5 Gy (range 2–19 Gy), respectively. Conclusions: The flex-dose delivery program represents a therapeutic protocol capable of “saving” portions of healthy liver parenchyma by designing a “custom-made” treatment for the patient. Full article

The aim of this study was to present our preliminary experience with transarterial radioembolization (TARE) using Yttrium-90 (⁹⁰Y), compare the cancer-specific survival (CSS) of patients with hepatocellular carcinoma (HCC) and colorectal cancer (CRC) liver metastases undergoing TARE, and investigate the influence of additional treatments on CSS. Our database was interrogated to retrieve patients who had undergone TARE using Yttrium-90 (⁹⁰Y) glass or resin microspheres. Kaplan–Meier curves and the log-rank test were employed to conduct survival analysis for the different groups (p < 0.05). Thirty-nine patients were retrieved (sex: 27 M, 12 F; mean age: 63.59 ± 15.66 years): twenty-three with hepatocellular carcinoma (HCC) and sixteen with CRC liver metastasis. Globally, the patients with HCC demonstrated a significantly longer CSS than those with CRC liver metastasis (22.64 ± 2.7 vs. 7.21 ± 1.65 months; p = 0.014). Among the patients with CRC liver metastasis, those receiving TARE and additional concomitant treatments (n = 10) demonstrated a longer CSS than the CRC patients receiving only TARE (9.97 ± 2.21 vs. 2.59 ± 0.24 months; p = 0.06). In the HCC group, there was a trend of a longer CSS in patients (n = 8) receiving TARE and additional treatments (27.89 ± 3.1 vs. 17.69 ± 3.14 months; p = 0.15). Patients with HCC seem to achieve a longer survival after TARE compared to patients with CRC liver metastases. In patients with CRC liver metastases, the combination of TARE and additional concomitant treatments may improve survival. Full article

Radiation segmentectomy is a versatile, safe, and effective ablative therapy for early-stage hepatocellular carcinoma. Advances in radiation segmentectomy patient selection, procedural technique, and dosimetry have positioned this modality as a curative-intent and guideline-supported treatment for patients with solitary HCC. This review describes key radiation segmentectomy concepts and summarizes the existing literary knowledgebase. Full article

The impact of yttrium 90 radioembolization (Y90-RE) in combination with immune checkpoint inhibitors (ICIs) has recently gained attention. However, it is unclear how sequencing and dosage affect therapeutic efficacy. The purpose of this study was to develop a mathematical model to simulate the synergistic effects of Y90-RE and ICI combination therapy and find the optimal treatment sequences and dosages. We generated a hypothetical patient cohort and conducted simulations to apply different treatments to the same patient. The compartment of models is described with ordinary differential equations (ODEs), which represent targeted tumors, non-targeted tumors, and lymphocytes. We considered Y90-RE as a local treatment and ICIs as a systemic treatment. The model simulations show that Y90-RE and ICIs administered simultaneously yield greater benefits than subsequent sequential therapy. In addition, applying Y90-RE before ICIs has more benefits than applying ICIs before Y90-RE. Moreover, we also observed that the median PFS increased up to 31~36 months, and the DM rates at 3 years decreased up to 36~48% as the dosage of the two drugs increased (p < 0.05). The proposed model predicts a significant benefit of Y90-RE with ICIs from the results of the reduced irradiated tumor burden and the associated immune activation and suppression. Our model is expected to help optimize complex strategies and predict the efficacy of clinical trials for HCC patients. Full article