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Radioembolization using Yttrium-90 (90 Y) microspheres is widely used to treat primary and metastatic liver tumors. The present work provides minimum practice guidelines for establishing and supporting such a program. Medical physicists play a key role in patient and staff safety during these procedures. Products currently available are identified and their properties and suppliers summarized. Appropriateness for use is the domain of the treating physician. Patient work up starts with pre-treatment imaging. First, a mapping study using Technetium-99m (Tc-99m ) is carried out to quantify the lung shunt fraction (LSF) and to characterize the vascular supply of the liver. An MRI, CT, or a PET-CT scan is used to obtain information on the tumor burden. The tumor volume, LSF, tumor histology, and other pertinent patient characteristics are used to decide the type and quantity of 90 Y to be ordered. On the day of treatment, the appropriate dose is assayed using a dose calibrator with a calibration traceable to a national standard. In the treatment suite, the care team led by an interventional radiologist delivers the dose using real-time image guidance. The treatment suite is posted as a radioactive area during the procedure and staff wear radiation dosimeters. The treatment room, patient, and staff are surveyed post-procedure. The dose delivered to the patient is determined from the ratio of pre-treatment and residual waste exposure rate measurements. Establishing such a treatment modality is a major undertaking requiring an institutional radioactive materials license amendment complying with appropriate federal and state radiation regulations and appropriate staff training commensurate with their respective role and function in the planning and delivery of the procedure. Training, documentation, and areas for potential failure modes are identified and guidance is provided to ameliorate them.

Cholangiocarcinoma is a hepatobiliary malignancy which can manifest anywhere along the biliary tree. Intrahepatic cholangiocarcinoma occurs in the liver within or beyond the second order bile ducts. The prognosis for patients with intrahepatic cholangiocarcinoma is poor, even when successfully resected there is a very high rate of local recurrence. The available systemic therapies are currently limited and have high rates of toxicity. Percutaneous and transarterial liver-directed therapies can be used to treat intrahepatic cholangiocarcinoma with results comparable to current standard of care systemic therapies in some circumstances. This manuscript will review these the techniques and efficacy of percutaneous and transarterial liver-directed therapies for intrahepatic cholangiocarcinoma. [ABSTRACT FROM AUTHOR]

Background and Aims Methods Results Conclusion Holmium‐166 (166Ho) radioembolization could offer a more individualized approach in terms of imaging and dosimetry. We aim to evaluate the feasibility and safety of 166Ho selective internal radiation therapy (SIRT) using a higher tumour dose than previously administered determined by 166Ho‐scout as a surrogate marker in HCC patients.This is an open‐label, prospective, non‐randomized, single‐centre pilot study that included patients with HCC that received 166Ho‐SIRT if the work‐up using 166Ho‐scout showed a tumour‐absorbed dose ≥150 Gy, a non‐tumoural liver absorbed dose less than 60 Gy and a lung absorbed dose less than 30 Gy. Primary endpoints were feasibility and safety–toxicity profiles at 24–48 h and 1 month. Overall response rates (ORR) at 3 months (mRECIST, RECIST 1.1 and metabolic response by FDG and choline PET CT) and time to progression (TTP) represented the secondary endpoints.Fifteen patients with large tumours (mean diameter 55.67 ± 28.42 mm) received 17 166Ho‐SIRT treatments between July 2020 and June 2022. All the attempted treatments were accomplished. Mean administered tumour dose was 183.18 ± 71.71 Gy, while non‐tumour liver dose was 30.29 ± 14.56 Gy. Median time of follow‐up was 12 months (IQR 9–16). Only grade 1–2 clinical and biological AEs were observed. There were no liver decompensations. At 3 months, objective response was achieved for all target lesions (CR 78.57%, PR 21.43% according to mRECIST). Median TTP was 18.8 (range 2.9; n.e.) months.Personalized 166Ho‐SIRT with a tumour delivered dose ≥150 Gy was feasible and safe for HCC patients with promising response rates. [ABSTRACT FROM AUTHOR]

Liver transplantation (LT) is a potentially curative experimental treatment for unresectable intrahepatic cholangiocarcinoma (iCC). Pre-transplant downstaging may help defining tumor aggressiveness and drive patient selection. We report the preliminary results of LT for liver-limited unresectable iCC after sequential downstaging with systemic chemotherapy and radioembolization (SYS-TARE). In case of sustained disease stability after SYS-TARE, patients underwent surgical nodal sampling and, if negative, were listed for LT. In this study, 13 patients with unresectable iCC underwent downstaging with SYS-TARE. The median age was 70 years and 77% were female. All had single bulky lesions at diagnosis. After SYS-TARE, 9 (69%) dropped out: 3 due to progressive disease after TARE with no response to second-line, 4 due to extrahepatic disease development and 2 due to positive nodal disease at pre-listing abdominal exploration. The median OS after dropout was 11.5 months. Four (31%) were successfully listed and transplanted. At pathology, viable tumor ranged from 30% to less than 5%. All four patients are alive and disease-free at 73, 40, 12, and 8 months from LT. LT for unresectable iCC after downstaging with SYS-TARE appears to select suitable patients for LT, achieving optimal oncological outcomes in case of response to therapy and no lymphnodal spread. [ABSTRACT FROM AUTHOR]

Aim: To meta-analyze the utility of transarterial radioembolization (TARE) in patients with liver metastatic breast cancer (BC), based on the objective response rate (ORR) and disease control rate (DCR). Methods: A literature search was performed retrieving studies with (1) at least 10 patients with liver metastatic BC treated with TARE and (2) adequate information to derive ORR and DCR. The ORR is the ratio between patients with liver lesions showing complete response (CR) or partial response (PR) over the total number of patients treated with TARE; the DCR is the ratio between patients with CR, PR, or stable disease (SD) over the total number of patients treated with TARE. Results: Eighteen studies (650 patients) were eligible; the ORR of TARE resulted 50.71% (95% C.I.: 40.04–61.36) and the DCR resulted 88.37% (95% C.I.: 81.89–93.57). Taking into account resin spheres (395 patients), the ORR was 60.35% (95% C.I.: 46.55–73.36) and the DCR was 92.73% (95% C.I.: 87.17–96.80%). Considering glass spheres (144 patients), the ORR was 32.38% (95% C.I.: 18.43–48.16) and the DCR was 82.69% (95% C.I.: 59.29–97.26). Conclusions: This meta-analysis favors the use of TARE in patients with liver metastatic BC either with resin or glass spheres. [ABSTRACT FROM AUTHOR]

Ablative therapies for primary and secondary liver malignancies are increasingly adopted in current guidelines. Nevertheless, surgical resection remains the gold standard in most curative therapy settings. Extensive studies on mortality and morbidity after ablative treatment of the liver are missing. We investigated complications and mortality after ablative treatment in a large, unselected study cohort. Standardized patient and treatment data in 4374 percutaneous and angiographic ablative procedures of the liver from the DRG-based hospital reimbursement system (diagnosis-related groups) of an academic hospital in Germany were retrospectively evaluated. We analyzed descriptive patient data, length of stay (LOS), pre-existing medical conditions, previous gastrointestinal surgeries, severe complications, and occurrence of death. Treatment of secondary liver malignancies constituted over two-thirds of all procedures (71%, n = 3053). The mean LOS was 4.1 ± 3.5 days. Severe complications were documented in 1.4% and in-house death in 0.2% of cases, significantly more often after treatment with chemoembolization of primary liver malignancies (p = 0.003; p = 0.0001). Previous partial liver resection, partial bowel resection, and chronic renal failure were independent risk factors for the occurrence of severe complications. Severe complications and in-hospital death are rare in the treatment of primary and secondary liver malignancies with percutaneous and angiographic procedures. They are a viable alternative or addition to a surgical approach in treating liver lesions. [ABSTRACT FROM AUTHOR]

Purpose: To assess the technical and clinical outcomes of percutaneous embolization for high-flow mesenteric vein to gonadal vein (MGV) portosystemic shunts. Methods: In this HIPPA-compliant, review board-approved study, patients who underwent embolization of MGV shunts between 2011 and 2023 were included. Patient demographic data, embolization technique, clinical outcomes, and complications were retrieved from the electronic health records. Technical success was defined as complete occlusion of the shunt on follow-up imaging. Clinical outcomes assessed were resolution/improvement of hepatic encephalopathy, improvement in liver function, changes to liver volumes, and occurrence of adverse events. Results: Eight patients (mean age 59.5, 75% female) with nine MGV shunts were included. The indications for shunt embolization included medically refractory hepatic encephalopathy, bleeding duodenal varices, and transplant liver dysfunction. The mean maximum shunt diameter was 23.3 mm. Embolization was most commonly performed with a combination of coils and N-butyl cyanoacrylate or vascular plugs. Complete MGV shunt thrombosis was achieved in 7/9 shunts post-embolization, and symptom improvement was noted in 7/8 patients. Child–Pugh scores improved post-embolization in 6/9 patients by a median of 3 points. Liver volumes also increased by a mean of 20.8 ± 17.7% post-embolization. Minor adverse events included new onset ascites, partial mesenteric/portal vein thrombosis, and new gastroesophageal varices without bleeding in four patients. Conclusion: Embolization of MGV shunts is technically feasible and effective for treatment of hepatic encephalopathy and increasing hepatopetal portal perfusion. There was an improvement in Child–Pugh scores and an increase in liver volumes in the majority of patients post-embolization. [ABSTRACT FROM AUTHOR]

This article aims at presenting in a didactic way, dosimetry concepts and methods that are relevant for radio-embolization of the liver with 90Y-microspheres. The application of the medical internal radiation dose formalism to radio-embolization is introduced. This formalism enables a simplified dosimetry, where the absorbed dose in a given tissue depends on only its mass and initial activity. This is applied in the single-compartment method, partition model, for the liver, tumour and lung dosimetry, and multi-compartment method, allowing identification of multiple tumours. Voxel-based dosimetry approaches are also discussed. This allows taking into account the non-uniform uptake within a compartment, which translates into a non-uniform dose distribution, represented as a dose--volume histogram. For this purpose, dose--kernel convolution allows propagating the energy deposition around voxel-sources in a computationally efficient manner. Alternatively, local-energy deposition is preferable when the spatial resolution is comparable or larger than the beta-particle path. Statistical tools may be relevant in establishing dose--effect relationships in a given population. These include tools such as the logistic regression or receiver operator characteristic analysis. Examples are given for illustration purpose. Moreover, tumour control probability modelling can be assessed through the linear-quadratic model of Lea and Catcheside and its counterpart, the normal-tissue complication probability model of Lyman, which is suitable to the parallel structure of the liver. The selectivity of microsphere administration allows tissue sparing, which can be considered with the concept of equivalent uniform dose, for which examples are also given. The implication of microscopic deposition of microspheres is also illustrated through a liver toxicity model, even though it is not clinically validated. Finally, we propose a reflection around the concept of therapeutic index (TI), which could help tailor treatment planning by determining the treatment safety through the evaluation of TI based on treatment-specific parameters. [ABSTRACT FROM AUTHOR]

A 78-year-old man with a history of GI stromal tumor (GIST) in the stomach with metastasis to the liver presented with progressive shortness of breath, dry cough, and subjective fever that started 1 week after radioembolization of liver metastatic lesions. His initial diagnosis of GIST was 10 years before, for which he underwent surgical resection; however, more recently he was noted to have hepatic lesions biopsy-proven to be metastatic GIST lesions. He stated that he did not have any respiratory symptoms before the radioembolization procedure and denied having a history of pulmonary disease. His medical history was otherwise notable for coronary artery disease post coronary artery bypass graft in 2002, heart failure with reduced ejection fraction, and atrioventricular block after pacemaker placement. After the diagnosis of liver metastasis, he began treatment with imatinib 6 months earlier and consequently received radioembolization with yttrium-90 (Y-90) microspheres. [ABSTRACT FROM AUTHOR]

Purpose: Transarterial 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. Methods: We 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. Results: We 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. Conclusions: Our 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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aim: To meta-analyze the utility of transarterial radioembolization (TARE) in patients with liver metastatic breast cancer (BC), based on the objective response rate (ORR) and disease control rate (DCR). Methods: A literature search was performed retrieving studies with (1) at least 10 patients with liver metastatic BC treated with TARE and (2) adequate information to derive ORR and DCR. The ORR is the ratio between patients with liver lesions showing complete response (CR) or partial response (PR) over the total number of patients treated with TARE; the DCR is the ratio between patients with CR, PR, or stable disease (SD) over the total number of patients treated with TARE. Results: Eighteen studies (650 patients) were eligible; the ORR of TARE resulted 50.71% (95% C.I.: 40.04–61.36) and the DCR resulted 88.37% (95% C.I.: 81.89–93.57). Taking into account resin spheres (395 patients), the ORR was 60.35% (95% C.I.: 46.55–73.36) and the DCR was 92.73% (95% C.I.: 87.17–96.80%). Considering glass spheres (144 patients), the ORR was 32.38% (95% C.I.: 18.43–48.16) and the DCR was 82.69% (95% C.I.: 59.29–97.26). Conclusions: This meta-analysis favors the use of TARE in patients with liver metastatic BC either with resin or glass spheres.

Unresectable hepatocellular carcinoma unresponsive to first-line immunotherapy has a poor prognosis with modest response to tyrosine kinase inhibitors in the second line. In these patients, the benefit of local therapy with immunotherapy rechallenge is unknown. Radioembolization is a guideline-supported locoregional therapy for HCC that has shown the potential for synergy in combination with immunotherapy. This report describes a patient with veno-invasive HCC and extrahepatic invasion of the right kidney which progressed on atezolizumab and bevacizumab and was subsequently downstaged to resection with ipilimumab and nivolumab plus radioembolization yielding a complete pathologic response. The patient is currently more than 2 years since diagnosis without evidence of disease recurrence.

Radiation induced cholecystitis is a known but rare complication of Yttrium90 (Y90) radioembolization of hepatic tumors due to nontarget embolization. Many documented cases of radiation induced cholecystitis have been treated with cholecystectomy, which is significant given the typical patient population undergoing radioembolization tends to be of higher surgical risk. Here, we present a case of a 68 year old male who developed radiation induced cholecystitis status post hepatic radioembolization that resolved with conservative management alone. This case highlights that radiation induced cholecystitis may be successfully and safely treated conservatively.

Yttrium-90 radioembolization is an effective treatment for liver cancers. However, deposition of radioactive microspheres in nondiseased liver can result in parenchymal injury. Segmental and subsegmental radioembolization may reduce off-target liver damage but may not always be possible due to anatomy. In this case report, we highlight the use of a microvascular plug (MVP) to protect distal nondiseased liver and redirect flow into the proximal tumor-containing liver volume during radioembolization of a gallbladder cancer recurrence. Throughout the report, we describe the technique, advantages, and limitations of using MVP-assisted temporary vascular occlusion during organ protection.

Abstract Metal artifacts notoriously pose significant challenge in computed tomography (CT), leading to inaccuracies in image formation and interpretation. Artifact reduction tools have been designed to improve cone beam computed tomography (CBCT) image quality by reducing artifacts caused by certain high-density materials. Metal artifact reduction (MAR) tools are specific algorithms that are applied during image reconstruction to minimize or eliminate artifacts degrading CBCT images. The purpose of the study is to evaluate the effect of a MAR algorithm on image quality in CBCT performed for evaluating patients before transarterial radioembolization (TARE). We retrospectively included 40 consecutive patients (aged 65 ± 13 years; 23 males) who underwent 45 CBCT examinations (Allura FD 20, XperCT Roll protocol, Philips Healthcare, Best, The Netherlands) in the setting of evaluation for TARE between January 2017 and December 2018. Artifacts caused by coils, catheters, and surgical clips were scored subjectively by four readers on a 5-point scale (1 = artifacts affecting diagnostic information to 5 = no artifacts) using a side-by-side display of uncorrected and MAR-corrected images. In addition, readers scored tumor visibility and vessel discrimination. MAR-corrected images were assigned higher scores, indicating better image quality. The differences between the measurements with and without MAR were most impressive for coils with a mean improvement of 1.6 points (95%CI [1.5 1.8]) on the 5-point likert scale, followed by catheters 1.4 points (95%CI [1.3 1.5]) and clips 0.7 points (95%CI [0.3 1.1]). Improvements for other artifact sources were consistent but relatively small (below 0.25 points on average). Interrater agreement was good to perfect (Kendall’s W coefficient = 0.68–0.95) and was higher for MAR-corrected images, indicating that MAR improves diagnostic accuracy. A metal artifact reduction algorithm can improve diagnostic and interventional accuracy of cone beam CT in patients undergoing radioembolization by reducing artifacts caused by diagnostic catheters and coils, lowering interference of metal artifacts with adjacent major structures, and improving tumor visibility.

Background: Preoperative vascular embolization is an effective strategy for managing meningiomas, neck paragangliomas, renal cell carcinomas, and bone metastasis by reducing the intraoperative bleeding volume and operation time. Although hypervascular tumors also occur in the pancreas, preoperative embolization for these tumors is not commonly practiced. We herein present a case of a giant serous cystic neoplasm (SCN) of the pancreas with significant arterial vascularity that was managed with preoperative interventional radiology and subsequently resected via pancreaticoduodenectomy. Case presentation: A 60-year-old man presented with an 8-cm hypervascular tumor located at the head of the pancreas, identified as an SCN on pathologic examination. The tumor had increased by 13 mm over 5 years, necessitating surgical intervention. Computed tomography revealed a substantial blood supply to the tumor from the dorsal pancreatic artery and gastroduodenal artery, both branches of the superior mesenteric artery. To mitigate the risk of severe intraoperative bleeding from this giant hypervascular tumor, branches of the dorsal pancreatic artery and gastroduodenal artery were embolized using metallic coils and further secured using a gelatin sponge 1 day prior to pancreatectomy. During the laparotomy, the tumor appeared to have decreased in size, likely because of reduced distension and congestion. Despite significant adhesions to surrounding tissues secondary to prolonged compression and inflammation, the pancreaticoduodenectomy was completed successfully in 5 h and 15 min with blood loss of 763 mL. The patient was discharged on postoperative day 15 without complications. Conclusions: Preoperative arterial embolization for hypervascular pancreatic tumors might control the risk of massive intraoperative bleeding, contributing to a favorable postoperative outcome. Utilizing interventional radiology for preoperative inflow control is one of the beneficial strategies for pancreatectomy in patients with a giant SCN. [ABSTRACT FROM AUTHOR]

OBJECTIVE: In uterine artery embolization (UAE) for the treatment of fibroids, nondegradable particles permanently occlude the uterine artery (UA). These particles remain in the vessels and can cause secondary undesirable effects, such as severe pain after embolization and fertility issues. In this prospective experimental study, we aimed to evaluate the angiographic recanalization, local and systemic reactions, and uterine damage occurring after performing UAE with newly developed degradable starch microspheres (DSMs) in sheep. MATERIALS AND METHODS: Under general anesthesia, eight nonpregnant sheep underwent bilateral UAE using DSMs to achieve stasis. Angiographic evaluation was performed on days 1, 3 and 7 after embolization to assess in vivo recanalization. In addition, the angiographic series were scored via a modified embolization score. A postmortem tissue examination was performed to determine whether DSMs and foreign body inflammatory reactions were present and to assess uterine necrosis. RESULTS: Complete bilateral embolization of the UA and cervicovaginal branches was achieved in all treated animals. Recanalization of the occluded arteries was evident in 25 of 27 arteries during the angiographic evaluation. In all sheep, there were multifocal areas of uterine necrosis, and some uterine vessels contained intraluminal material consistent with DSMs. The average weight of both uterine horns was significantly correlated with both the number of microspheres needed for complete embolization (r = 0.69, ρ<0.01) and the average percentage of necrosis in both uterine horns (r = 0.64, ρ<0.05). CONCLUSIONS: Our findings demonstrated the efficacy of vascular embolization with DSM by inducing ischemic changes in the uterus and subsequent recanalization of previously occluded arteries. [ABSTRACT FROM AUTHOR]

Background/aim: Y2O3-Al2O3-SiO2 (YAS) glass microspheres are currently used in radioembolization treatment. However, abscess formation can occur following this treatment. This study aims to endow YAS glass microspheres with antibacterial properties to address the abscesses forming in patients after radioembolization treatment. Materials and methods: In this study, undoped YAS glass microspheres and those doped with antibacterial agents zinc (Zn) and/or copper (Cu) were successfully fabricated using a sol-gel derived method. Results: After heat treatment, the microspheres exhibited an amorphous structure. Additionally, the incorporation of Zn and/or Cu dopants did not alter the patterns observed in the X-ray diffraction analysis. Fourier transform infrared spectroscopy analysis detected Si-O-Si, Al-O-Al, and Y-O band vibrations within the structure. The presence of Zn and Cu dopants was confirmed through X-ray photoelectron spectroscopy analysis. Scanning electron microscopy revealed that all samples possessed a regular microsphere morphology, with average particle sizes ranging from 6 to 50 µm. These average particle sizes were further confirmed using a mastersizer. Conclusion: The antibacterial agent-doped YAS glass microspheres show promise in combating infections that occur following radioembolization treatment. [ABSTRACT FROM AUTHOR]

Background: Following yttrium‐90 radioembolization (90Y‐RE), 90Y‐PET/CT and 90Y‐SPECT/CT imaging provide the means to calculate the voxelized absorbed dose distribution. Given the widespread use of the two imaging modalities and lack of well‐established standardized dosimetry protocols for 90Y‐RE, there is a clinical need to systematically investigate and evaluate differences in the performance of voxel‐based dosimetry between 90Y‐PET/CT and 90Y‐SPECT/CT. Purpose: To quantitatively analyze and compare 90Y‐PET/CT and 90Y‐SPECT/CT‐based dosimetry following 90Y‐RE. Methods: 90Y‐PET/CT and 90Y‐SPECT/CT imaging was acquired for 35 patients following 90Y‐RE with TheraSphere for the treatment of unresectable hepatocellular carcinoma. Dosimetry was performed using the local deposition method with known activity and the mean dose (Dmean) was calculated for perfused liver volumes (PV), tumors (T), and perfused normal livers (NL). Additionally, the absorbed dose to x% of the volume (Dx, x ∈$ \in $ [5%, 10%, ..., 90%, 95%]) and the volume receiving y Gy (Vy, y ∈$ \in $ [10 Gy, 20 Gy, ..., 190 Gy, 200 Gy]) were calculated for T and NL, respectively. Dose metrics were compared using linear regression, Bland‐Altman analysis, and statistical testing. Results: Both 90Y‐SPECT/CT and 90Y‐PET/CT‐based tumor Dmean were strongly correlated (R2 ≥ 0.90) with Dx, excluding metrics on the extrema. Intra‐modality comparisons of various Dx and Vy metrics yielded statistically significant differences (ANOVA, p < 0.001) for both90Y‐PET/CT and 90Y‐SPECT/CT. Based on statistical testing, only Dx metrics separated by greater than 20%–30% coverage, and only Vy metrics separated by greater than 40–70 Gy, reported significant differences. For PV, there was a strong correlation (R2 ≥ 0.99) between Dmean derived separately from 90Y‐PET/CT and 90Y‐SPECT/CT imaging. The strength of the correlation was slightly reduced for T and NL with R2 = 0.91 and R2 = 0.95, respectively. For PV, the mean bias ± standard error (SE) and 95% limits of agreement (LOA) between Dmean from the two modalities was effectively zero with ‐0.8 ± 0.4% (± 2.5%). For T and NL, the mean bias ± SE (± LOA) was ‐14.5 ± 3.7% (± 24%) and 9.4 ± 4.7% (± 27%), respectively. Conclusion: The strong correlation between Dmean and Dx suggests information from multiple dose metrics (e.g., D70 and Dmean) is largely redundant when establishing dose‐response relationships in 90Y‐RE. Dmean is highly correlated between 90Y‐PET/CT and 90Y‐SPECT/CT‐based dosimetry, for all liver VOIs. Relative to 90Y‐SPECT/CT, 90Y‐PET/CT, on average, yielded higher Dmean to tumors (14%) and lower Dmean to perfused normal livers (9%). Absorbed dose differences for perfused liver volumes between 90Y‐SPECT/CT and 90Y‐PET/CT were negligible. [ABSTRACT FROM AUTHOR]

Background: Yttrium‐90 (90Y) positron emission tomography (PET)/computed tomography (CT) imaging is increasingly being used to perform tumor (T) and normal liver (NL) voxel dosimetry after 90Y‐radioembolization (90Y‐RE). Yet, the accuracy of in vivo 90Y‐PET/CT imaging, subject to motion blur and co‐registration inaccuracies, and 90Y‐PET/CT dose quantification, subject to availability of different voxel dosimetry algorithms, are not well understood. Purpose: The purpose of this study was to investigate the accuracy of 90Y‐PET/CT‐based activity estimates following 90Y‐RE and characterize differences between 90Y‐PET/CT‐based voxel dosimetry algorithms. Methods: Thirty‐five patients underwent 90Y‐PET/CT imaging after 90Y‐RE with TheraSphere. The net administered 90Y activity (Aadmin) was determined using a dose calibrator and pre‐ and post‐procedure exposure rate measurements. The summation of image‐based activity (Aimage) was extracted from perfused volume (PV) and 3D‐isotropically 2‐cm expanded PV contour (PV+2 cm). Absorbed doses were calculated using voxel S‐value (VSV), local deposition method (LDM), and LDM with known activity (LDMKA) dosimetry algorithms. Linear regression and Bland‐Altman analysis quantified the relationship between Aimage and Aadmin and between mean dose estimates (DLDM, DVSV, DLDM‐KA) for PV, T, and perfused NL volumes. Results: While Aadmin and Aimage in PV were highly correlated (R2 > 0.95), the mean bias ± standard error (SE) and (95% limits of agreement, LOA) was significantly non‐zero with −22.7 ± 4.7% (± 28.4%). In PV+2 cm, the mean bias ± SE (± LOA) decreased to 1.3 ± 3.4% (± 18.0%) consistent with zero mean error. DLDM and DVSV were highly correlated (R2 > 0.99) for all volumes of interest (VOIs) and the mean bias ± SE (± LOA) was 2.2 ± 0.2% (± 1.0%), 0.7 ± 0.4% (± 2.8%), and 3.2 ± 0.5% (± 2.8%) for PV, T, and NL, respectively. DLDM‐KA and DVSV were correlated with R2 = 0.86, 0.80, and 0.86 for PV, T, and NL, respectively. The mean bias ± SE (± LOA) between DLDM‐KA and DVSV was significantly non‐zero with −19.6 ± 5.1% (± 31.0%), −20.8 ± 4.4% (± 29.0%), and −18.1 ± 5.3% (± 31.1%) for PV, T, and NL, respectively. Conclusions: The summation of Aimage in PV was underestimated relative to Aadmin. Only by accounting for respiratory motion, limited spatial resolution, and PET/CT co‐registration errors through VOI expansion was Aimage, on average, equal to Aadmin. The differences between DLDM and DVSV were not clinically relevant, though DLDM‐KA was approximately 20% greater than DVSV. Given the high quantitative accuracy of dose calibrators and challenges associated with accurate 90Y‐PET/CT quantification, LDMKA is the preferred algorithm for accurate 90Y‐PET/CT‐based dosimetry following 90Y‐RE. [ABSTRACT FROM AUTHOR]

Simple Summary: Potential curative options for hepatocellular carcinoma include liver transplant, surgical resection, and ablation. Unfortunately, only 15–30% of patients are eligible for curative options at the time of presentation. Therefore, it is crucial to explore and evaluate treatment methods than can potentially convert nonsurgical candidates into surgical candidates. One such treatment option that can be used as a conversion strategy is yttrium-90 radioembolization. This study examines the success rate of using boosted dose radiation segmentectomy to convert nonsurgical candidates into eligible candidates for transplant or surgical resection. Background/Objectives: The aim of this study was to assess the efficacy of boosted dose yttrium-90 radioembolization (TARE) as a modality for conversion therapy to transplant or surgical resection in patients with unresectable hepatocellular carcinoma (HCC). Methods: In this single-center retrospective study, all patients with a diagnosis of HCC who were treated with boosted dose TARE (>190 Gy) between January 2013 and December 2023 were reviewed. Treatment response and decrease in tumor size were assessed with the RECIST v1.1 and mRECIST criteria. Milan and University of California, San Francisco (UCSF), criteria were used to determine transplant eligibility, and Barcelona Clinic Liver Cancer (BCLC) surgical resection recommendations were used to evaluate tumor resectability. Results: Thirty-eight patients with primary HCC who were treated with boosted dose TARE were retrospectively analyzed. The majority of the patients were Child–Pugh A (n = 35; 92.1%), BCLC C (n = 17; 44.7%), and ECOG performance status 0 (n = 25; 65.8%). The mean sum of the target lesions was 6.0 cm (standard deviation; SD = 4.0). The objective response rate (ORR) was 31.6% by RECIST and 84.2% by mRECIST. The disease control rate (DCR) was 94.7% by both RECIST and mRECIST. Among patients outside of Milan or UCSF, 13/25 (52.0%, Milan) and 9/19 (47.4%, UCSF) patients were successfully converted to within transplant criteria. Of patients who were initially unresectable, conversion was successful in 7/26 (26.9%) patients. Conclusions: This study provides further real-world data demonstrating that boosted-dose TARE is an effective modality for conversion of patients with unresectable HCC to transplant or resection. [ABSTRACT FROM AUTHOR]

Background: Hepatic vein embolization in double vein embolization (DVE) can be performed with transhepatic, transjugular or transfemoral access. This study evaluates the feasibility and technical success of using a transfemoral access for the hepatic vein embolization in patients undergoing preoperative to induce hypertrophy of the future liver remnant (FLR). Material and methods: Retrospective analysis of single center cohort including 17 consecutive patients. The baseline standardized FLR was 18.2% (range 14.7–24.9). Portal vein embolization was performed with vascular plugs and glue through an ipsilateral transhepatic access. Hepatic vein embolization was performed using vascular plugs. Access for the hepatic vein was either transhepatic, transjugular or transfemoral. Technical success, number of hepatic veins embolized and complications were registered. In addition, volumetric data including degree of hypertrophy (DH) and kinetic growth rate (KGR), and resection data were registered. R: Seven of the 17 patients had transfemoral hepatic vein embolization, with 100% technical success. No severe complications were registered. In the whole cohort, the median number of hepatic veins embolized was 2 (1–6). DH was 8.6% (3.0–19.4) and KGR was 3.6%/week (1.4–7.4), without significant differences between the patients having transfemoral versus transhepatic /transjugular access (p = 0.48 and 0.54 respectively). Time from DVE to surgery was median 4.8 weeks (2.6–33.9) for the whole cohort, with one patient declining surgery, two having explorative laparotomy and one patient having change of surgical strategy due to insufficient growth. Conclusion: Transfemoral access is a feasible option with a high degree of technical success for hepatic vein embolization in patients with small future liver remnants needing DVE. [ABSTRACT FROM AUTHOR]

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   g / c 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. [ABSTRACT FROM AUTHOR]

Purpose: Transarterial radioembolization (TARE) for hepatocellular carcinoma (HCC) is performed after a mapping angiogram involving infusion of radiolabeled macroaggregated albumin to assess for non-target embolization and pulmonary shunting. The purpose of this case series was to evaluate the safety and feasibility of single-session TARE without the initial procedure. Materials and Methods: A single-institution case series of 16 consecutive procedures on 15 patients with 18 tumors who underwent an attempted single-session TARE procedures with glass microspheres are presented. A lung shunt fraction (LSF) of 5% was assumed for planning purposes. Results: Sixty-seven percent (10/15) of patients were male with a median age of 72 years. Median tumor size was 2.5 cm (IQR 2.0–3.2 cm). Sixteen of the 18 targeted tumors were untreated prior to the single-session TARE. Rate of technical success was 88% (14/16). Two patients did not ultimately receive a single-session TARE due to intraprocedural findings. The mean administered activity was 2.0 GBq, and the mean MIRD dose was 464 Gy based on pre-treatment anatomic imaging and 800 Gy based on cone-beam CT. There were no cases of radiation pneumonitis. Mean post-procedural calculated lung dose was 4.9 Gy (range 3.1–9.3) based on SPECT. Conclusions: An initial experience with single-session TARE using Y-90 glass microspheres without pre-procedural mapping angiography and lung shunt estimation demonstrates that it is a feasible and safe treatment option for select patients with small (< 5 cm) HCC. Level of Evidence IV: Level 4 case series. [ABSTRACT FROM AUTHOR]

Purpose: An international survey was conducted by the Cardiovascular Interventional Radiological Society of Europe (CIRSE) to evaluate radioembolization practice and capture opinions on real-world clinical and technical aspects of this therapy. Materials and Methods: A survey with 32 multiple choice questions was sent as an email to CIRSE members between November and December 2022. CIRSE group member and sister societies promoted the survey to their local members. The dataset was cleaned of duplicates and entries with missing data, and the resulting anonymized dataset was analysed. Data were presented using descriptive statistics. Results: The survey was completed by 133 sites, from 30 countries, spanning 6 continents. Most responses were from European centres (87/133, 65%), followed by centres from the Americas (22/133, 17%). Responding sites had been performing radioembolization for 10 years on average and had completed a total of 20,140 procedures over the last 5 years. Hepatocellular carcinoma treatments constituted 56% of this total, colorectal liver metastasis 17% and cholangiocarcinoma 14%. New sites had opened every year for the past 20 years, indicating the high demand for this therapy. Results showed a trend towards individualized treatment, with 79% of responders reporting use of personalized dosimetry for treatment planning and 97% reporting routine assessment of microsphere distribution post-treatment. Interventional radiologists played an important role in referrals, being present in the referring multi-disciplinary team in 91% of responding centres. Conclusion: This survey provides insight into the current state of radioembolization practice globally. The results reveal the increasing significance placed on dosimetry, evolving interventional techniques and increased technology integration. [ABSTRACT FROM AUTHOR]

Purpose: To compare the treatment outcomes of glass and resin microspheres for the treatment of hepatocellular carcinoma (HCC) and evaluate the prognostic factors that influence the outcomes. Materials and Methods: We retrospectively reviewed 251 consecutive patients who underwent radioembolization for the treatment of HCC at a single tertiary center. Imaging responses after radioembolization were evaluated using the modified Response Evaluation Criteria in Solid Tumors (mRECIST) 1.1. Progression-free survival (PFS) and overall survival (OS) were analyzed using the Kaplan–Meier method. Univariate and multivariate Cox proportional hazard models were used to identify the prognostic factors. Results: A total of 195 patients were included in this study (glass microsphere, n = 75; resin microsphere, n = 120). The complete and objective response rates were 16.0% and 50.7% in the glass microsphere group and 17.5% and 58.3% in the resin microsphere group, respectively. Median PFS was 241 days in the glass microsphere group and 268 days in the resin microsphere group (p = 0.871). Median OS was 29 months in the glass microsphere group and 40 months in the resin microsphere group (p = 0.669). The only significant prognostic factor was bilobar tumor distribution, which favored resin microspheres (p = 0.023). Procedure-related adverse events occurred more frequently in the resin microsphere group (glass, 2.7% vs. resin, 5.0%; p < 0.001). Conclusion: Glass and resin microspheres for the treatment of HCC did not show a significant difference in survival, though major adverse events occurred more frequently with the use of resin microspheres. [ABSTRACT FROM AUTHOR]

Introduction: Intrahepatic cholangiocarcinoma (ICC) is the 2nd most common primary liver malignancy. For nonsurgical candidates, the primary treatment option is systemic chemotherapy, which can be combined with locoregional therapies to enhance local control. Common intra-arterial locoregional therapies include transarterial hepatic embolization, conventional transarterial chemoembolization, drug-eluting bead transarterial chemoembolization, transarterial radioembolization with Yttrium-90 microspheres, and hepatic artery infusion. This article aims to review the latest literature on intra-arterial locoregional therapies for treating ICC. Areas covered: A literature search was conducted on PubMed using keywords: intrahepatic cholangiocarcinoma, intra-arterial locoregional therapy, embolization, chemoembolization, radioembolization, hepatic artery infusion, and immunotherapy. Articles from 2008 to 2024 were reviewed. Survival data from retrospective and prospective studies, meta-analyses, and clinical trials were evaluated. Expert opinion: Although no level I evidence supports the superiority of any specific intra-arterial therapy, there has been a shift toward favoring radioembolization. In our expert opinion, radioembolization may offer superior outcomes when performed by skilled operators with meticulous planning and personalized dosimetry, particularly for radiation segmentectomy or treating lobar/bilobar disease in appropriate candidates. [ABSTRACT FROM AUTHOR]

Background: Subtraction of single-photon emission computed tomography (SPECT) images has a number of clinical applications in e.g. foci localization in ictal/inter-ictal SPECT and defect detection in rest/stress cardiac SPECT. In this work, we investigated the technical performance of SPECT subtraction for the purpose of quantifying the effect of a vasoconstricting drug (angiotensin-II, or AT2) on the Tc-99m-MAA liver distribution in hepatic radioembolization using an innovative interventional hybrid C-arm scanner. Given that subtraction of SPECT images is challenging due to high noise levels and poor resolution, we compared four methods to obtain a difference image in terms of image quality and quantitative accuracy. These methods included (i) image subtraction: subtraction of independently reconstructed SPECT images, (ii) projection subtraction: reconstruction of a SPECT image from subtracted projections, (iii) projection addition: reconstruction by addition of projections as a background term during the iterative reconstruction, and (iv) image addition: simultaneous reconstruction of the difference image and the subtracted image. Results: Digital simulations (XCAT) and phantom studies (NEMA-IQ and anthropomorphic torso) showed that all four methods were able to generate difference images but their performance on specific metrics varied substantially. Image subtraction had the best quantitative performance (activity recovery coefficient) but had the worst visual quality (contrast-to-noise ratio) due to high noise levels. Projection subtraction showed a slightly better visual quality than image subtraction, but also a slightly worse quantitative accuracy. Projection addition had a substantial bias in its quantitative accuracy which increased with less counts in the projections. Image addition resulted in the best visual image quality but had a quantitative bias when the two images to subtract contained opposing features. Conclusion: All four investigated methods of SPECT subtraction demonstrated the capacity to generate a feasible difference image from two SPECT images. Image subtraction is recommended when the user is only interested in quantitative values, whereas image addition is recommended when the user requires the best visual image quality. Since quantitative accuracy is most important for the dosimetric investigation of AT2 in radioembolization, we recommend using the image subtraction method for this purpose. [ABSTRACT FROM AUTHOR]

Simple Summary: Malignant diseases represent a central challenge in modern medicine. Despite improved screening approaches and advanced diagnostics, malignant diseases such as HCC are still diagnosed at non-resectable/advanced stages. In these cases, minimally invasive treatment methods such as SIRT or other radioablation procedures are of particular importance as part of personalized oncological therapy. When choosing the right minimally invasive procedure, it would be useful to be able to use biomarkers as predictors of treatment response. With this background, the aim of this study is to evaluate the usefulness of CCL2 as a predictor of treatment response and survival. Purpose: Hepatocellular carcinoma (HCC) is the largest subgroup of primary liver tumors. Ablative therapies, such as selective internal radiation therapy (SIRT), are used in late stages for patients with unresectable liver metastases and no response to other therapies. CCL2 (C-C motif chemokine ligand 2) is a potent monocyte chemoattractant. It is associated with tumor progression and metastasis. The role of circulating CCL2 as a biomarker in HCC undergoing selective internal radiation therapy remains unclear. Methods: A total of 41 patients (8 female, 33 male) suffering from HCC and undergoing SIRT were enrolled. Pre- and post-therapy changes in circulating CCL2 levels were determined by bead-based immunoassay and compared with clinical laboratory parameters and patient data. Results: A total of 32 patients exhibited survival beyond 60 days. It was observed that levels of CCL2 correlated with scores indicating a higher likelihood of non-survival and with the severity of the disease. Moreover, a significant inverse correlation was discovered between CCL2 levels and the survival of patients over 60 days in relation to counts of leukocytes, granulocytes, monocytes, and C-reactive protein. Conclusions: CCL2 may serve as a potential marker for patient survival after SIRT. The prediction of which HCC patients are likely to benefit from SIRT may be helpful in guiding therapeutic management. [ABSTRACT FROM AUTHOR]

Medullary thyroid carcinoma (MTC) can often have an indolent course despite distant metastatic disease. Additionally, given that metastatic MTC is incurable and systemic therapies have non-negligeable toxicities, localized treatments are often favored in presence of oligo-progressive disease. Transarterial radioembolization (TARE) with yttrium-90 (Y90) has emerged as a safe and efficacious treatment for nonresectable primary and metastatic liver tumors, yet data supporting its use in metastatic MTC are limited. We present the case of a patient with hereditary MTC and large bilobar liver metastases who demonstrated tumor response and resolution of their paraneoplastic diarrhea following TARE with Y90 microspheres. [ABSTRACT FROM AUTHOR]

Yttrium-90 radioembolization is an effective treatment for liver cancers. However, deposition of radioactive microspheres in nondiseased liver can result in parenchymal injury. Segmental and subsegmental radioembolization may reduce off-target liver damage but may not always be possible due to anatomy. In this case report, we highlight the use of a microvascular plug (MVP) to protect distal nondiseased liver and redirect flow into the proximal tumor-containing liver volume during radioembolization of a gallbladder cancer recurrence. Throughout the report, we describe the technique, advantages, and limitations of using MVP-assisted temporary vascular occlusion during organ protection. [ABSTRACT FROM AUTHOR]

This study aimed to determine which comorbidities were associated with intractable epistaxis requiring electrocauterization or embolization, and to identify the location where intractable epistaxis frequently occurred. The patients were divided into two groups: patients with epistaxis successfully controlled in outpatient department (OPD) and those with intractable epistaxis in OPD which was controlled by surgical exploration or arterial embolization (OP/EM). Evaluations of the bleeding locations, related vessels, and patient's comorbidities were conducted. A total of 41 patients from the OP/EM group and 725 patients from the OPD group were enrolled. The following comorbidities showed elevated risks of the intractable epistaxis (p < 0.05) in multivariate analysis; hypertension (OR 1.089, 95% CI 1.049 - 1.132), dyslipidemia (1.132, 1.041 - 1.232), liver cirrhosis (1.272, 1.152 - 1.406), chronic obstructive pulmonary disease (1.234, 1.078 - 1.412) and asthma (1.205, 1.053 - 1.379). Inferior and middle turbinate were equally the most common location of the intractable bleeding. In patients with epistaxis requiring hemostatic treatments, comorbidities such as hypertension, dyslipidemia, liver diseases, COPD, and asthma were associated with intractable epistaxis. The main bleeding sites of intractable epistaxis were the middle and inferior turbinate. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to explore influencing factors and clinical significance of ultra-long-term microischemia following intracranial aneurysm (IA) embolization and establish a theoretical foundation for reducing both the incidence of ultra-long-term microischemia and cognitive dysfunction in patients post embolization. Methods: A retrospective analysis was conducted on data from 147 patients who received endovascular treatment for IAs. Patients were categorized into microischemic and control (non-microischemic) groups on the based on the findings of high-resolution magnetic resonance vessel wall imaging (HR-VWI) examinations performed 3 days postoperatively and 6 months postoperatively. Risk factors for the occurrence of ultra-long-term microischemia were determined by univariate analysis and multivariate logistic regression analysis. Results: Out of 147 patients included in the study, 51 (34.69%) developed microischemia while the remaining 96 (65.31%) did not experience this condition. Analysis revealed that factors such as sex, age, history of underlying diseases (hypertension, diabetes mellitus), aneurysmal site characteristics, the presence or absence of stenosis in the aneurysm-bearing artery, modified Fisher score at admission, Barthel's index at discharge, immunoinflammatory index at 3 days postoperatively and at the 6-month follow-up, the presence or absence of aneurysmal wall enhancement, and the presence or absence of aneurysmal lumen showed no statistically significant differences between the two groups (all P > 0.05). By contrast, variables like in operative time, rupture status of the aneurysm before surgery according to World Federation of Neurologic Surgeons (WFNS) grade, aneurysm size, number of stents used, number of guidewires and catheters used, and Evans index between the two groups were found to have statistically significant disparities between those who developed microischemia and those who did not (P < 0.05). A subsequent multivariate analysis revealed that aneurysm size, Evans index, and the number of stents used were independent risk factors for the occurrence of ultra-long-term microischemia after surgical intervention of aneurysms (P < 0.05). The receiver operating characteristic (ROC) curves of the patients were constructed on the basis of risk factors determined through multivariate logistic regression analysis. Results indicated that aneurysm size (area under ROC curve (AUC) 0.619, sensitivity 94.7%, specificity 17.1%, P = 0.049), Evans index (AUC 0.670, sensitivity 96.4%, specificity 26.8%, P = 0.004), and number of stents (AUC 0.639, sensitivity 44.6%, specificity 90.2%, P < 0.001) effectively predicted the occurrence of microischemia. The incidence of cognitive dysfunction was higher in the microischemic group than in the control group (P < 0.05), and a greater number of microischemic foci was associated with a higher incidence of cognitive dysfunction. The proportion of microschemia foci in the thalamus and basal ganglia in patients with cognitive dysfunction (60.87%) was significantly higher than that in patients without cognitive dysfunction (34.55%) (P < 0.05). Conclusion: Aneurysm size, Evans index > 0.3, and the quantity of stents were independent risk factors for the occurrence of ultra-long-term microischemia after aneurysm embolization and provided good predictive performance. Cognitive dysfunction was closely associated with microischemia, with its severity increasing with an increase in the number of ischemic foci. [ABSTRACT FROM AUTHOR]

Background Evaluating transarterial radioembolization (TARE) in patients with metastatic colorectal carcinoma of the liver who have progressed on first-line chemotherapy (EPOCH) demonstrated superior outcomes using yttrium-90 glass microspheres plus chemotherapy (TARE/Chemo) vs chemotherapy (Chemo) to treat colorectal liver metastases. Additional exploratory analyses were undertaken to assess the impact of TARE/Chemo on efficacy, safety, time to subsequent therapy, time to deterioration in quality of life (QoL), and identify criteria for improved patient selection. Methods Time to deterioration in QoL was analyzed for the primary study population. Subsequently, a post hoc analysis was undertaken to identify subgroups for which time to deterioration in QoL was improved with TARE/Chemo vs Chemo. Progression-free survival (PFS), hepatic (h)PFS, time to subsequent therapy, and safety outcomes were compared between treatments. Results The primary population showed no significant difference in time to deterioration in QoL between treatment arms; however, significance was seen in 2 identified subgroups, namely: Subgroup A (N  = 303) which excluded patients with both Eastern Cooperative Oncology Group (ECOG) 1 and baseline CEA ≥ 35 ng/mL from both treatment arms; subgroup B (N  = 168) additionally excluded patients with KRAS (Kirsten rat sarcoma) mutation. In subgroup A, TARE/Chemo patients (N  = 143) demonstrated superior outcomes vs Chemo (N  = 160): PFS (9.4 vs. 7.6 months, hazard ratio (HR): 0.64; 1-sided P  = .0020), hPFS (10.8 vs. 7.6 months, HR: 0.53; 1-sided P  < .0001), time to deterioration in QoL (5.7 vs. 3.9 months, HR: 0.65; 1-sided P  = .0063), and time to subsequent therapy (21.2 vs. 10.5 months, HR: 0.52; 1-sided P  < .0001). Subgroup B patients showed similar but larger significant differences between treatment arms. Median PFS, hPFS, and time to deterioration in QoL were numerically greater for TARE/Chemo in both subgroups vs the primary population, with the greatest magnitude of difference in subgroup B. Both subgroups exhibited higher percentage of CEA responders and improved ORR with TARE/Chemo vs chemo alone. Safety (reported as event rate/100 patient-years) was higher with Chemo in all populations. Additional efficacy analyses in the primary population are also reported. Conclusions Careful patient selection, including consideration of the prognostic factors ECOG, baseline CEA, and KRAS status, sets outcome expectations in patients with colorectal liver metastases suitable for TARE/Chemo as second-line treatment (Trial Registry Number: NCT01483027). [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: An intermediate catheter (IMC) may pose a risk of intraprocedural rupture (IPR) during coil embolization of ruptured intracranial aneurysms (RIAs), because the pressure on the microcatheter and coil might be more direct. To verify this hypothesis, this study explored whether use of an IMC might correlate with an increased rate of IPR during coil embolization for RIAs. Methods: We retrospectively reviewed 195 consecutive aneurysms in 192 patients who underwent initial coil embolization for saccular RIAs at our institution between January 2007 and December 2023. Patients were divided into two groups with aneurysms treated either with an IMC (IMC group) or without an IMC (non-IMC group). To investigate whether IMC use increased the rate of IPR, a propensity score-matched analysis was employed to control for age, sex, maximal aneurysm size, neck size, bleb formation, aneurysm location, proximal vessel tortuosity, balloon-assisted coiling, type of microcatheter, and type of framing coil. Results: Ultimately, 43 (22%) coil embolization used IMC. In univariate analysis, the incidence of IPR was significantly higher in the IMC group compared with the non-IMC group (14.0 vs. 3.3%, p  =  0.016). Propensity score matching was successful for pairs of 26 aneurysms in the IMC group and 52 aneurysms in the non-IMC group. The incidence of IPR was still significantly higher in the IMC group than in the non-IMC group (23.1 vs. 3.8%, p =  0.015). No significant differences in the incidences of ischemic complications and IMC-related parent artery dissection were observed between the two groups. Discussion: When using IMC for coil embolization of RIAs, the surgeons should be more careful and delicate in manipulating the microcatheter and inserting the coils to avoid IPR. [ABSTRACT FROM AUTHOR]

Background: Sepsis is triggered by pathogenic microorganisms, resulting in a systemic inflammatory response. Liver cirrhosis and sepsis create a vicious cycle: cirrhosis weakens immune function, raising infection risk and hindering pathogen clearance. Optimal treatment outcomes depend on understanding liver cirrhosis patients' sepsis risk factors. Thus, preventing sepsis involves addressing these risk factors. Therefore, early identification and understanding of clinical characteristics in liver cirrhosis patients with sepsis are crucial for selecting appropriate antibiotics. A case-control study using logistic regression was conducted to examine the prognostic value of amyloid A/lactate level monitoring in identifying sepsis risk factors in liver cirrhosis patients. Methods: From March 2020 to March 2022, 136 liver cirrhosis patients treated at our hospital were divided into a sepsis group (n = 35) and a non-sepsis group (n = 101) based on sepsis complications. General clinical data were collected. Univariate analysis screened for liver cirrhosis patients' sepsis risk factors. Multivariate logistic analysis was subsequently employed to evaluate the risk factors. Sepsis patients were followed up for a month. Based on prognosis, patients were categorized into a poor prognosis group (n = 16) and a good prognosis group (n = 19). Serum amyloid A (SAA) and blood lactic acid (BLA) levels were compared between the two groups. The receiver operating characteristic (ROC) curve was used to evaluate the prognostic value of both individual and combined SAA/BLA monitoring. Results: Patient data, including age, diabetes history, liver cancer, hepatic artery embolization, recent antibiotic use, invasive procedures within two weeks, APACHE II Scoring, ALB and SAA and BLA levels, were compared between the sepsis and non-sepsis groups, showing significant differences (P < 0.05). Logistic regression identified factors such as age ≥ 70, recent antibiotic use, recent invasive procedures, history of liver cancer, hepatic artery embolization history, high APACHE II scores, decreased albumin, and elevated SAA and BLA levels as independent sepsis risk factors in liver cirrhosis patients (P < 0.05). Among the 35 sepsis patients, 16 had a poor prognosis, representing an incidence rate of 45.71%. Serum SAA and BLA levels were significantly higher in the poor prognosis group than in the good prognosis group (P < 0.05). The AUC for serum SAA and BLA was 0.831 (95%CI: 0.738–0.924), 0.720 (95%CI: 0.600–0.840), and 0.909 (95%CI: 0.847–0.972), respectively. The combined diagnostic AUC was significantly higher than that of single factor predictions (P < 0.05). The predictive value ranked as follows: joint detection > SAA > BLA. Conclusion: In treating liver cirrhosis, prioritize patients with advanced age, a history of hepatic artery embolization, recent invasive operations, history of liver cancer, recent antibiotic exposure, high APACHE II scores and low albumin. Closely monitoring serum SAA and BLA levels in these patients can offer valuable insights for early clinical prevention and treatment. [ABSTRACT FROM AUTHOR]

Metal artifacts notoriously pose significant challenge in computed tomography (CT), leading to inaccuracies in image formation and interpretation. Artifact reduction tools have been designed to improve cone beam computed tomography (CBCT) image quality by reducing artifacts caused by certain high-density materials. Metal artifact reduction (MAR) tools are specific algorithms that are applied during image reconstruction to minimize or eliminate artifacts degrading CBCT images. The purpose of the study is to evaluate the effect of a MAR algorithm on image quality in CBCT performed for evaluating patients before transarterial radioembolization (TARE). We retrospectively included 40 consecutive patients (aged 65 ± 13 years; 23 males) who underwent 45 CBCT examinations (Allura FD 20, XperCT Roll protocol, Philips Healthcare, Best, The Netherlands) in the setting of evaluation for TARE between January 2017 and December 2018. Artifacts caused by coils, catheters, and surgical clips were scored subjectively by four readers on a 5-point scale (1 = artifacts affecting diagnostic information to 5 = no artifacts) using a side-by-side display of uncorrected and MAR-corrected images. In addition, readers scored tumor visibility and vessel discrimination. MAR-corrected images were assigned higher scores, indicating better image quality. The differences between the measurements with and without MAR were most impressive for coils with a mean improvement of 1.6 points (95%CI [1.5 1.8]) on the 5-point likert scale, followed by catheters 1.4 points (95%CI [1.3 1.5]) and clips 0.7 points (95%CI [0.3 1.1]). Improvements for other artifact sources were consistent but relatively small (below 0.25 points on average). Interrater agreement was good to perfect (Kendall's W coefficient = 0.68–0.95) and was higher for MAR-corrected images, indicating that MAR improves diagnostic accuracy. A metal artifact reduction algorithm can improve diagnostic and interventional accuracy of cone beam CT in patients undergoing radioembolization by reducing artifacts caused by diagnostic catheters and coils, lowering interference of metal artifacts with adjacent major structures, and improving tumor visibility. [ABSTRACT FROM AUTHOR]

Significant improvements within radioembolization imaging and dosimetry permit the development of an accurate and personalized pretreatment plan with technetium 99 m –labeled macroaggregated albumin single-photon emission computed tomography (99m Tc-MAA SPECT/CT). Despite these potential advantages, the clinical transition to pretreatment protocols with SPECT/CT is hindered by its unknown safety constraints. This study aimed to address this issue by establishing novel dose limits for 99m Tc-MAA SPECT/CT to enable quantitative pretreatment planning. Stratification criteria to determine images most viable for dosimetry analysis were created from a cohort of 85 patients. SPECT/CT, cone beam CT, and activity calculations derived from the local deposition method were used to create an accurate pretreatment protocol. Planar and SPECT/CT images were compared using linear regression and modified Bland-Altman analyses to convert accepted planar dose limits to SPECT/CT. To validate these new dose limits, activity calculations based on SPECT/CT were compared with those calculated with the body surface area and planar methods for 3 treatment plans. A total of 38 of 85 patients were deemed viable for dosimetry analysis. SPECT lung shunt fractions (LSFs) yielded greater values than planar imaging when LSFs were <4.89%, whereas planar imaging was greater than SPECT when LSFs were >4.89. Planar to SPECT/CT dose safety conversions were 0.76 ×, 0.70 ×, and 0.55 × for the whole liver, normal liver, and lungs, respectively. Patients with SPECT LSFs <4.89% were safely treated with the direct application of planar lung dose limits. Activity calculations with SPECT/CT were greater than the body surface area method by a median of 33.1% to 61.9% and were lower than planar-based activity calculations by 12.5% to 13.7% for the whole liver and by 29.4% to 32.2% for the normal liver. A generalized method to establish safety dose limits between 2 modalities was used to translate safety dose limits from planar imaging to 99m Tc-MAA SPECT/CT. An accurate 99m Tc-MAA SPECT/CT treatment protocol was developed guided by the current knowledge in the field. Established SPECT/CT dose limits safely treated 97.5% of patients and permitted the application of independent pretreatment planning with 99m Tc-MAA SPECT/CT. [ABSTRACT FROM AUTHOR]

Intrahepatic cholangiocarcinoma is one of the most aggressive forms of cancer. It is usually diagnosed in advanced stages of the disease, mainly because it is asymptomatic for a long time after the onset. Consequently, intrahepatic cholangiocarcinoma still represents an important problem of diagnosis and treatment. In the multidisciplinary treatment of these patients, oncological surgery is essential, as the accuracy of resection is one of the most important prognostic factors for the long-term results of these patients. Therefore, there has been a continuing concern to improve surgical techniques, with the aim of maximizing the chances of achieving the best possible long-term survival. The purpose of this paper is to discuss the surgical standard of care in intrahepatic cholangiocarcinoma, with particular attention being paid to resection margins and lymph node dissection. For unresectable cholangiocarcinoma, locoregional therapy can be used such as transarterial chemoembolization, transarterial radioembolization, thermal ablation, radiotherapy and hepatic artery infusion pump chemotherapy. [ABSTRACT FROM AUTHOR]

Objectives: To compare the survival and objective response rate (ORR) of the patients receiving estimated tumour absorbed dose (ETAD) <140 Gy versus ETAD ≥140 Gy in patients with advanced chemorefractory colorectal carcinoma liver metastases (CRCLM) treated with yttrium-90 transarterial radioembolization (90Y TARE). Methods: Between August 2016 and August 2023 adult patients with unresectable, chemorefractory CRCLM treated with 90Y TARE using glass particles, were retrospectively enrolled. Primary outcomes were overall survival (OS) and hepatic progression free survival (hPFS). Secondary outcome was ORR. Results: A total of 40 patients with a mean age of 66.2 ± 7.8 years met the inclusion criteria. Mean ETAD for group 1 (ETAD <140 Gy) and group 2 (ETAD ≥140) were 131.2 ± 17.4 Gy versus 195 ± 45.6 Gy, respectively. The mean OS and hPFS for group 1 versus group 2 were 12 ± 10.3 months and 8.1 ± 9.3 months versus 9.3 ± 3 months and 7.1 ± 8.4 months, respectively and there were no significant differences (P = .181 and P = .366, respectively). ORR did not show significant difference between the groups (P = .432). Conclusion: In real-world practice, no significant difference was found in OS, hPFS, and ORR between patients who received ETAD <140 Gy versus ETAD ≥140 Gy in patients with CRCLM, in this series. Advances in knowledge: This study demonstrated that increased tumour absorbed doses in radioembolization may not provide additional significant advantage for OS and hPFS for patients with CRCLM. [ABSTRACT FROM AUTHOR]

To quantitatively investigate the longitudinal computed tomography perfusion (CTP) imaging in meningiomas preoperatively embolized using microcatheters. This retrospective monocentric study included 27 patients with symptomatic supratentorial meningiomas. Quantitative computed tomography perfusion (CTP) images before and postembolization were evaluated and correlated with angiographic, immunohistochemical, and clinical data. The mean age of the patients was 45 ± 18 years, with a female-to-male ratio of 1.45:1. After embolization, both the embolized (Eb) and unembolized (UEb) regions showed hypoperfusion. A steady state was achieved on days 4–6 postembolization, during which differences in regional cerebral blood volume (rCBV) (Eb 0.5 ± 0.3 ml/100 mg, UEb 3.3 ± 1.4 ml/100 mg; P < 0.05), and mean transit time (MTT) (Eb 3.5 ± 1.8 s, UEb 3.1 ± 0.4 s) were observed. The cerebral blood flow (rCBF) and time to the peak (TTP) exhibited opposite patterns between Eb and UEb. A steady state was reached in rCBF (Eb 1.7 ± 1.2 ml/100 g/min, UEb 30 ± 5.4 ml/100 g/min; P < 0.01), and TTP (Eb 5 ± 4.8 s, UEb 1.8 ± 1.5 s; P < 0.01) within 4 to 6 days. Estimated blood loss (EBL) showed significant association with the surgical time interval among the 3 groups (P < 0.05). Tissue necrosis predominated over 7 days postembolization, indicating a correlation with the devascularization process. The overall incidence of postembolized headache, seizures, extremity weakness/paralysis, and postoperational headache was 11.1%, 7.4%, 3.7%; and 7.4%, respectively. All symptoms resolved by the last follow-up (3 months). Preoperative embolization of meningiomas using N-butyl cyanoacrylate effectively induced significant and sustained tissue transformation and decreased estimated blood loss (EBL) over 7 days. Hemodynamic fluctuations tended to stabilize within 4 to 6 days. [ABSTRACT FROM AUTHOR]

Transarterial radioembolization (TARE) with 166Ho-loaded microspheres is an established locoregional treatment for hepatocellular carcinoma (HCC), introduced in 2010. This study evaluates the clinical outcome of patients with HCC who underwent 166Ho-TARE with personalized dosimetry. Twenty-seven patients with 36 TARE procedures were analyzed. Treatment planning, execution, and evaluation was possible without complications in all cases. At the 3-month follow-up, disease control in the treated liver was achieved in 81.8% of patients (complete remission, partial remission, and stable disease in 36.4%, 31.8%, and 13.6%, respectively). The median overall survival (OS) was 17.2 months, and progression-free survival (PFS) in the treated liver was 11 months. Statistically significant positive correlations were observed between the achieved radiation dose for the tumor and both PFS (r = 0.62, p < 0.05) and OS (r = 0.48, p < 0.05), suggesting a direct dose–response relationship. The calculated achieved dose was 8.25 Gy lower than the planned dose, with relevant variance between planned and achieved doses in individual cases. These results confirm the efficacy of the 166Ho-TARE holmium platform and underscore the potential of voxel-based, personalized dosimetry to improve clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Drug resistance is a major obstacle in the treatment of anaplastic thyroid carcinoma (ATC) with the combination of docetaxel (DTX) and doxorubicin (DOX). Excessive intracellular drug efflux is considered a key factor contributing to drug resistance. Therefore, developing drug-loaded microspheres to enhance cellular uptake and inhibit efflux of docetaxel and doxorubicin may be an effective strategy to overcome chemoresistance. Methods: Alginate-Doxorubicin@carboxymethyl chitosan-Docetaxel (A-DOX@C-DTX) microspheres were prepared using an electrostatic spraying-assisted microfluidic device. The microspheres were characterized, and the in vitro drug release profiles and extracellular efflux rates were determined. The effects of A-DOX@C-DTX microspheres on drug-resistant ATC cells were evaluated in vitro. In vivo, a subcutaneous tumor model was established in mice to investigate the effects of A-DOX@C-DTX microspheres on tumor growth, as well as the accumulation and release of the materials at the tumor site. Results: We successfully prepared aliginate/carboxymethyl chitosan (ALG/CMC) microspheres with a core-shell structure. These microspheres exhibited controllable size, good monodispersity, excellent biocompatibility, high encapsulation efficiency for doxorubicin and docetaxel, and high drug loading capacity. Moreover, the microspheres promoted cellular uptake of doxorubicin and docetaxel while inhibiting their efflux. A-DOX@C-DTX microspheres showed significant inhibition of viability, proliferation, migration, and invasion of drug-resistant ATC cells in vitro. In vivo, A-DOX@C-DTX microspheres suppressed tumor growth, induced tumor tissue necrosis, and promoted tumor cell apoptosis. In addition, the microspheres facilitated the enrichment of active substances in the tumor and their sustained release. Conclusion: A-DOX@C-DTX microspheres exhibited superior antitumor effects compared to free drug treatment both in vitro and in vivo, particularly against drug-resistant ATC cells. This improved therapeutic efficacy may be attributed to the enhanced drug uptake and reduced drug efflux in drug-resistant ATC cells facilitated by ALG/CMC microspheres. [ABSTRACT FROM AUTHOR]

Simple Summary: Discovering hypervascular incidentalomas (HVIs) during intra-arterial therapies (IATs) for hepatocellular carcinoma (HCC) is a common condition, but guidelines lack precise management suggestions. This study examines whether to include HVIs in IAT for HCC patients awaiting liver transplantation. A retrospective study analyzed liver-transplanted HCC patients who received TACE or TARE before LT from 2014 to 2018. The study compared HCC detection rates between pre-interventional imaging and per-interventional CBCT and investigated correlations between HVIs and poor prognosis criteria. Results showed higher nodule detection with CBCT and no significant correlations between HVIs and poor prognosis criteria, tumor recurrence, or mortality. Kaplan–Meier analysis found no significant impact of HVIs on recurrence-free, recurrence-related, or overall survival. These data may indicate that the treatment plan during IAT should not be impacted or modified in response to HVI detection in patients awaiting LT. Background: Current guidelines do not indicate any comprehensive management of hepatic hypervascular incidentalomas (HVIs) discovered in hepatocellular carcinoma (HCC) patients during intra-arterial therapies (IATs). This study aims to evaluate the prognostic value of HVIs detected on per-interventional cone beam computed tomography (CBCT) during IAT for HCC in patients waiting for liver transplantation (LT). Material and methods: In this retrospective single-institutional study, all liver-transplanted HCC patients between January 2014 and December 2018 who received transarterial chemoembolization (TACE) or radioembolization (TARE) before LT were included. The number of ≥10 mm HCCs diagnosed on contrast-enhanced pre-interventional imaging (PII) was compared with that detected on per-interventional CBCT with a nonparametric Wilcoxon test. The correlation between the presence of an HVI and histopathological criteria associated with poor prognosis (HPP) on liver explants was investigated using the chi-square test. Tumor recurrence (TR) and TR-related mortality were investigated using the chi-square test. Recurrence-free survival (RFS), TR-related survival (TRRS), and overall survival (OS) were assessed according to the presence of HVI using Kaplan–Meier analysis. Results: Among 63 included patients (average age: 59 ± 7 years, H/F = 50/13), 36 presented HVIs on per-interventional CBCT. The overall nodule detection rate of per-interventional CBCT was superior to that of PII (median at 3 [Q1:2, Q3:5] vs. 2 [Q1:1, Q3:3], respectively, p < 0.001). No significant correlation was shown between the presence of HVI and HPP (p = 0.34), TR (p = 0.095), and TR-related mortality (0.22). Kaplan–Meier analysis did not show a significant impact of the presence of HVI on RFS (p = 0.07), TRRS (0.48), or OS (p = 0.14). Conclusions: These results may indicate that the treatment plan during IAT should not be impacted or modified in response to HVI detection. [ABSTRACT FROM AUTHOR]

Purpose: This study assessed the safety and effectiveness of a technical modification that involves adding short gastric artery (SGA) embolization to left gastric artery (LGA) embolization. Material and Methods: This retrospective single-center study analyzed twenty obese patients (median age of 53.5 (30–73)) who were not eligible for bariatric surgery and underwent bariatric embolization with 300–500-µm microspheres in addition to a lifestyle counseling program between March 2021 and July 2022. Eight patients had LGA + SGA embolization, and twelve had LGA embolization alone. The primary outcome measure was total body weight loss (TBWL) at 6 months in the SGA + LGA and the LGA-only cohorts. Safety was assessed, defined as the 30-day adverse events rate according to the SIR classification. Results: The mean 6-month post-embolization TBWL in the SGA + LGA cohort was 7.3 kg (95%CI 2.1–12.4; p =.01) and 4.1 kg (95%CI 0.4–8.6; p = 0.034) in the LGA-only cohort (mean difference − 3.1 kg ± 2.8; 95%CI (− 9.1–2.8); p =.28). The mean 6-month post-embolization TBWL in the entire cohort was 5.3 kg (p <.01). The rate of complications was similar between the two groups. Conclusion: Combined SGA and LGA embolization is safe and effective to treat obesity. Larger studies are needed to determine whether SGA + LGA embolization results in more significant weight loss than LGA embolization alone. [ABSTRACT FROM AUTHOR]

Transarterial embolization, the first-line treatment for hepatocellular carcinoma, does not always lead to promising outcomes in all patients. A better understanding of how the immune lymphocyte changes after transarterial embolization might be the key to improve the efficacy of transarterial embolization. However, there are few studies evaluating immune lymphocytes in transarterial embolization patients. Therefore, we aimed to evaluate the short- and long-term effects of transarterial embolization on lymphocyte subsets in patients with hepatocellular carcinoma to identify those that predict transarterial embolization prognosis. Peripheral blood samples were collected from 44 patients with hepatocellular carcinoma at the following time points: 1 d before the initial transarterial embolization, 3 d after the initial transarterial embolization, and 1 mo after the initial transarterial embolization and subjected to peripheral blood mononuclear cell isolation and flow cytometry. Dynamic changes in 75 lymphocyte subsets were recorded, and their absolute counts were calculated. Tumor assessments were made every 4 to 6 wk via computed tomography or magnetic resonance imaging. Our results revealed that almost all lymphocyte subsets fluctuated 3 d after transarterial embolization, but only Tfh and B cells decreased 1 mo after transarterial embolization. Univariate and multivariate Cox regression showed that high levels of Th2 and conventional killer Vδ2 cells were associated with longer progressive-free survival after transarterial embolization. Longer overall survival after transarterial embolization was associated with high levels of Th17 and viral infection–specific Vδ1 cells and low levels of immature natural killer cells. In conclusion, transarterial embolization has a dynamic influence on the status of lymphocytes. Accordingly, several lymphocyte subsets can be used as prognostic markers for transarterial embolization. [ABSTRACT FROM AUTHOR]