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Background & Aims: SORAMIC is a previously published randomised controlled trial assessing survival in patients with advanced hepatocellular carcinoma who received sorafenib with or without selective internal radiation therapy (SIRT). Based on the per-protocol (PP) population, we assessed whether the outcome of patients receiving SIRT+sorafenib vs. sorafenib alone was affected by adverse effects of SIRT on liver function., Methods: The PP population consisted of 109 (SIRT+sorafenib) vs. 173 patients (sorafenib alone). Comparisons were made between subgroups who achieved a significant survival benefit or trend towards improved survival with SIRT and the inverse group without a survival benefit: <65 years-old vs. ≥65 years-old, Child-Pugh 5 vs. 6, no transarterial chemoembolisation (TACE) vs. prior TACE, no cirrhosis vs. cirrhosis, non-alcohol- vs. alcohol-related aetiology. The albumin-bilirubin (ALBI) score was used to monitor liver function over time during follow-up., Results: ALBI scores increased in all patient groups during follow-up. In the PP population, ALBI score increases were higher in the SIRT+sorafenib than the sorafenib arm (p = 0.0021 month 4, p <0.0001 from month 6). SIRT+sorafenib conferred a survival benefit compared to sorafenib alone in patients aged <65 years-old, those without cirrhosis, those with Child-Pugh 5, and those who had not received TACE. A higher increase in ALBI score was observed in the inverse subgroups in whom survival was not improved by adding SIRT (age ≥65 years-old, p <0.05; cirrhosis, p = 0.07; Child-Pugh 6, p <0.05; prior TACE, p = 0.08)., Conclusion: SIRT frequently has a negative, often subclinical, effect on liver function in patients with hepatocellular carcinoma, which may impair prognosis after treatment. Careful patient selection for SIRT as well as prevention of clinical and subclinical liver damage by selective treatments, high tumour uptake ratio, and medical prophylaxis could translate into better efficacy., Clinical Trial Number: EudraCT 2009-012576-27, NCT01126645 LAY SUMMARY: This study of treatments in patients with hepatocellular carcinoma found that selective internal radiation therapy (SIRT) has an adverse effect on liver function that may affect patient outcomes. Patients should be carefully selected before they undergo SIRT and the treatment technique should be optimised for maximum protection of non-target liver parenchyma., Competing Interests: Conflict of interest Dr. Ricke reports grants from Sirtex Medical and Bayer AG, during the conduct of the study; personal fees from Sirtex Medical, Bayer, Boston Scientific, Bristol-Myers Squibb, EISAI, LaForce, Roche, Lilly Deutschland GmbH, Siemens Healthineers, Medison Pharma, MCI Deutschland, and LIAM GmbH, outside the submitted work. Dr. Schinner nothing to disclose. Dr. Seidensticker reports grants from Sirtex Medical and Bayer AG, during the conduct of the study; personal fees from Sirtex Medical, Bayer, and LIAM GmbH, outside the submitted work. Dr. Gasbarrini nothing to disclose. Dr. van Delden nothing to disclose. Dr. Amthauer reports grants from Sirtex Medical and Bayer AG, during the conduct of the study; lecture and/or personal fees from Sirtex Medical, Pfizer, Terumo, EISAI, GE, Novartis and Norgine, outside the submitted work. Dr. Peynircioglu reports personal fees from Bayer, Sirtex Medical, and Boston Scientific outside the submitted work. Dr. Bargellini reports personal fees from Sirtex Medical, Terumo, Boston Scientific, BTG, EISAI, Bayer, Guerbet, and GE Healthcare, outside the submitted work. Dr. Iezzi nothing to disclose. Dr. De Toni has served as a paid consultant for AstraZeneca, Bayer, BMS, EISAI, Eli Lilly & Co, Pfizer, IPSEN, Terumo, and Roche. He has received reimbursement of meeting attendance fees and travel expenses from Arqule, AstraZeneca, BMS, Bayer, Celsion, and Roche, and lecture honoraria from BMS and Falk. He has received third-party funding for scientific research from Arqule, AstraZeneca, BMS, Bayer, Eli Lilly, IPSEN, and Roche. Dr Malfertheiner reports grants from Bayer and Sirtex, during the conduct of the study, as well as personal fees from Aboca, Alfasigma, Bayer Healthcare, Danone, Malesci, and Menarini. Dr. Pech reports grants from Bayer Healthcare, grants and personal fees from Sirtex. Dr. Sangro reports consulting or advisory activities with Adaptimmune, AstraZeneca, Bayer, BMS, Boston Scientific/BTG, Eisai, Eli-Lilly, Ipsen, Onxeo, Roche, and Sirtex; speaker activities with AstraZeneca, Bayer, BMS, Ipsen, Lilly, Roche, and Sirtex; research grants (to institution) with BMS and Sirtex. Please refer to the accompanying ICMJE disclosure forms for further details., (Copyright © 2021 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)