PURPOSE:To find the maximum tolerated dose (MTD) of yttrium-90 (90Y) glass microspheres, with drug-eluting beads preloaded with irinotecan (DEBIRI) in patients with colorectal liver metastases (CRLMs). MATERIALS AND METHODS:In this prospective study, participants with bilobar, unresectable, liver-dominant CRLM progressing after first-line systemic therapy received sequential bilobar 90Y glass microsphere radioembolization at increasing dose levels (60-Gy, 80-Gy, and 100-Gy perfused normal liver absorbed doses), followed by DEBIRI, using a 3 + 3 dose-escalation design. The primary endpoint was MTD determination. Secondary endpoints included objective response rate (ORR) by Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 and Positron Emission Tomography Response Criteria in Solid Tumors (PERCIST), (serious) adverse events ([S]AEs), carcinoembryonic antigen (CEA) response, conversion to resection, and overall survival. Descriptive statistics and independent t-tests were applied. RESULTS:Twelve participants were enrolled. One dose-limiting toxicity (DLT; possible treatment-related fatal liver failure) occurred in the 80-Gy cohort, with no additional DLTs after cohort expansion (n = 6). At 100 Gy, 2 additional DLTs (probable and possible treatment-related fatal liver failure) occurred, establishing 80 Gy as the MTD when combined with full-dose DEBIRI. Eighty treatment-related (S)AEs occurred, most commonly increased gamma-glutamyl transferase (12/12, Grades 1-3) and abdominal pain (10/12, Grades 1-2). ORRs were 9% (RECIST) and 18% (PERCIST). Index lesion response rates were 20% (RECIST) and 35% (PERCIST). CEA response occurred in 42%. CONCLUSIONS:In this Phase I study in patients with liver-dominant colorectal metastases, receiving a combination of 90Y radioembolization with DEBIRI combined with DEBIRI, the MTD was 80 Gy. Considerable treatment-related toxicity was observed, and ORRs were limited.

Background This topical review aims to provide an overview of current literature on diagnostic modalities for vascular thoracic outlet syndrome (TOS) and evaluates their clinical applicability. Additionally, a structured diagnostic pathway is proposed for the assessment of arterial TOS (ATOS) and venous TOS (VTOS). Methods Given the absence of standardized guidelines, limited high-quality evidence, and heterogeneous cohorts, this review adopts a topical rather than a systematic approach. A comprehensive literature search of peer-reviewed articles between 2000 and 2006 was conducted in Pubmed. The available literature is summarized to assess the advantages, limitations, and clinical utility of each modality. Results Imaging plays a vital role in the evaluation of vascular TOS, although protocols vary substantially between centers. For suspected ATOS, computed tomography angiography, using a dedicated TOS protocol is proposed as the preferred initial modality, while computed tomography venography with TOS protocol is recommended for suspected VTOS. In patients presenting with suspected upper-extremity deep vein thrombosis, duplex ultrasound is recommended for initial assessment. Contrast angiography is reserved for selected cases when noninvasive imaging is inconclusive or when endovascular intervention is anticipated. Chest radiography and photoplethysmography appear to have limited additional diagnostic value. Intravascular ultrasound may offer complementary information in selected patients with VTOS. Conclusion The diagnostic complexity of vascular TOS underscores the importance of an integrated approach combining clinical evaluation and imaging, preferably within specialized expert centers. The proposed diagnostic pathway provides a practical framework and may serve as a step toward uniformity in clinical practice across different centers.

Purpose: The Cardiovascular and Interventional Radiological Society of Europe (CIRSE) conducted an international survey on the real-life application of transarterial radioembolization (TARE). This sub-analysis of the complete survey evaluates intercontinental disparities in TARE practices. Materials and Methods: A survey of 32 multiple-choice questions was distributed to CIRSE members between November and December 2022. The questions addressed steps of the TARE workflow, including treatment work-up, planning and dosimetry, intervention, follow-up and innovations. Responses were curated to remove duplicates and incomplete entries and categorised into continental groups. Analysis focused on variations between Europe and North America and impacting factors in the respective regions were identified. Data is presented using descriptive statistics. Results: Responses were obtained from 30 countries and 133 hospitals, including 87 European and 21 North American centres. Hepatocellular carcinoma was the most common indication, constituting 61% of treatments in North America and 51% in Europe. North America predominantly used 90Y glass microspheres, whereas Europe used 90Y resin. Procedural differences included the adoption of intra-procedural CT imaging, utilized by all North American sites, versus 89% of European sites. Outpatient treatments were favoured in North America (85%), while in Europe, most patients remained hospitalized for one night (51%). Both regions increasingly emphasized dosimetry-guided treatments, with personalized dosimetry planning in 71% and 84% of North American and European sites, respectively. Conclusions: This North America-Europe comparison highlights regional differences in radioembolization practice between the leading continents in procedure volume, based on results of the CIRSE TARE survey. Specific intercontinental differences identified in this survey included hospitalization, product utilization, and procedural techniques.

Insufficiency of the future liver remnant (FLR) precludes surgery for liver tumors as it is associated with post-hepatectomy liver failure (PHLF). A common strategy to induce pre-operative FLR hypertrophy is portal vein embolization of the tumor bearing liver lobe. More recently, transarterial radio-embolization (radiation lobectomy, RL) has been employed. Direct functional assessment using 99mTc-mebrofenin-hepatobiliary-scintigraphy (HBS) predicts FLR sufficiency more accurately than conventional volume assessment. However, studies describing dynamic functional assessment of the FLR after RL as induction for surgery are currently lacking. This study aims to compare FLR functional changes after PVE and RL. This non-interventional retrospective single-center cohort study was performed between 2016 and 2024. Patients with colorectal liver metastases (CRLM) who underwent PVE or RL because of an insufficient FLR (HBS < 2.7

BACKGROUND:Combined ablation and resection (CARe) reduces the need for major resection in patients with extensive colorectal liver metastases (CRLM). This study compares short-term outcomes of minimally invasive CARe (MI-CARe) vesus open CARe (O-CARe) for CRLM. METHODS:This nationwide cohort study used data from the Dutch Hepato Biliary Audit (2018-2022) on adults undergoing single-session CARe for CRLM in the Netherlands. Perioperative outcomes up to 30 days postoperatively of MI-CARe and O-CARe were compared using Propensity Score Matching (PSM). Long-term oncological data were unavailable. A survey assessed variation in indications, techniques, and experience across hospitals. RESULTS:A marked increase in MI-CARe was observed over the study period (16% in 2018 to 25% in 2022). Unmatched analysis revealed that O-CARe was more often applied in patients with more extensive disease, characterized by more CRLM, bilobar involvement and use of neoadjuvant chemotherapy. After PSM, MI-CARe was associated with reduced intraoperative blood loss (median 200 mL [IQR 100 - 500] vs 350 mL [IQR 150 - 800], p =< 0.001) and shorter hospital stays (median 3 days [IQR 2 - 5] vs 6 days [IQR 4 - 8], p < 0.001). No significant differences were observed in postoperative morbidity, readmission, or mortality. Considerable variation exists among hospitals in CARe practices. CONCLUSION:MI-CARe appears feasible and safe for selected patients, and leads to shorter hospital stays and lower blood loss than O-CARe. Variation in practice and the lack of oncological data preclude conclusions about its superiority.

Dosimetry-guided treatment planning is central to radioembolization. Guidelines recommend segmenting volumes on baseline contrast-enhanced CT (ceCT) and registering to a SPECT/low-dose CT. However, this conventional approach is vulnerable to spatial misregistration and potential disease progression. This study evaluates a hybrid SPECT/ceCT-based planning methodology, hypothesising that it yields significantly different dosimetry metrics compared to the conventional workflow. Hybrid SPECT/ceCT was performed in 24 patients with hepatocellular carcinoma. Treatment planning followed both the conventional and hybrid workflow, where delineation was performed directly on SPECT/ceCT. Quantification of dosimetric and positional differences between volumes from the two workflows was performed using Simplicit90Y (Mirada Medical) and SurePlan Liver Y90 (MIM) software, respectively. Outcomes were evaluated by Bland-Altman analysis and contour intercomparison indices. Direct delineation on SPECT/ceCT yielded higher index lesion (largest single tumour) doses (6

Purpose: Hepatobiliary scintigraphy (HBS) provides quantitative assessment of (future remnant) liver function, aiding clinical decision-making for surgical resection and radioembolization of hepatocellular carcinoma (HCC). However, its role for thermal ablation remains unexplored. This pilot study aimed to explore the potential role of HBS in guiding patient selection and risk stratification for thermal ablation. Methods: All HCC patients who underwent thermal ablation between January 2021 and August 2025 and had HBS performed prior to ablation were retrospectively reviewed. Ablated non-tumor liver volumes (i.e., volume of ablated healthy parenchyma) were quantified using 3D segmentation. Absolute ablated liver function (i.e., the proportion of total HBS-derived liver function ablated) was also assessed. Clinical outcomes included changes in clinical scores (e.g., Child-Pugh) and the occurrence of hepatic decompensation after ablation. Results: Nine patients (13 tumors) were included. Median global HBS-derived liver function was 3.2%/min/m2 (range 1.6-6.8%/min/m2). Three patients developed hepatic decompensation > 3 months after ablation, unlikely related to thermal ablation itself. The patient with the lowest baseline function (1.6%/min/m2) tolerated ablation without hepatic decompensation. Median ablated non-tumor liver volume was 14.4 cm3 (range 3.1-46.7 cm3), corresponding to a median of 0.9% (range 0.2-3.6%) of total liver volume ablated per lesion. Median absolute ablated function was 0.05%/min/m2 (range 0.02-0.21%/min/m2). Conclusions: Thermal ablation was feasible and well tolerated even in patients with severely impaired liver function. Routine pre-ablation HBS does not appear necessary for thermal ablation of HCC, as only a small percentage of total functional liver volume is ablated.

This multisociety, multidisciplinary consensus—formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology—was developed to standardise the assessment of ablation margins in liver tumour thermal ablation. A modified Delphi process, consisting of two online surveys and a hybrid (online and in-person meeting in Innsbruk) consensus meeting of 72 experts from North America, South America, Europe, and Asia. Formal consensus was reached for 150 (75%) of 199 statements. Strong agreement was observed between interventional and surgical oncologists, with only 12 (6%) of 199 statements showing significantly different ratings. Participants agreed that ablation margins should be assessed and documented for every treated tumour. Margins should be assessed quantitatively in three dimensions, with contrast-enhanced CT or MRI, preferably intraprocedurally with ablation confirmation software. Ablation margins should be categorised as A0 (tumour completely covered with sufficient margin), A1 (tumour completely covered but insufficient margin), or A2 (portion of tumour remains unablated). This effort is, to our knowledge, the first international consensus initiative to define best-practice recommendations for margin assessment in liver tumour thermal ablation to standardise practices, aiming to improve and promote uniform outcomes.

Purpose: Percutaneous thermal ablation of hypervascular liver tumors is limited by lesion conspicuity on conventional imaging, challenges with ablative margin assessment, and unequal global access to advanced technologies such as ablation confirmation software and radioembolization. This review describes the selective intra-arterial lipiodol injection (SIALI) technique, its technical variations across institutions, and summarizes published clinical outcomes for SIALI-guided thermal ablation of hepatic malignancies. Methods: A narrative review was conducted through structured searches of the PubMed, Embase, and Cochrane databases using terms including “selective intra-arterial lipiodol injection,” “lipiodol-guided ablation,” “SIALI,” and “hepatic arterial lipiodol.” Studies were selected based on relevance to SIALI technique, clinical outcomes, and comparator techniques, including hepatic arteriography with C-arm CT-guided ablation (hepACAGA) and ablation confirmation software. Full-text peer-reviewed articles were included; conference abstracts and letters were excluded. No formal PRISMA-compliant inclusion or exclusion criteria were applied, consistent with the narrative review format. Results: Seven studies were identified, encompassing six retrospective cohort studies and one prospective randomized controlled trial, collectively comprising over 900 patients treated across institutions in Asia, Europe, and the United States. Across heterogeneous patient populations and technical approaches, SIALI-guided thermal ablation was associated with improved local tumor recurrence rates, local recurrence-free survival, and overall survival compared with conventional ultrasound- or CT-guided ablation alone in selected studies where comparator data were available, with favorable technical success rates in lesions otherwise occult on standard imaging. Conclusion: SIALI appears to be a technically feasible and potentially useful adjunct technique that may improve lesion conspicuity and enable real-time ablative margin assessment in the treatment of hypervascular liver tumors, particularly in settings without access to ablation confirmation software. The available evidence is predominantly retrospective, and prospective validation is needed before broad conclusions regarding oncologic outcomes can be drawn.

Thermal ablation offers a safer, less invasive, and more cost-effective curative-intent treatment for selected patients with primary and metastatic liver tumours than surgery; when done with appropriate technique, ablation can deliver similar oncological outcomes. However, effectiveness in routine practice varies because structured training, planning, and procedural governance remain scarce. These international multidisciplinary, multi-society guidelines—formally endorsed by the European Society of Surgical Oncology, the Cardiovascular and Interventional Radiological Society of Europe, and the Society of Interventional Oncology—define key domains contributing to procedural difficulty and practice variation in liver tumour thermal ablation. A Delphi consensus initiative held in Innsbruck, Austria, engaged 72 experts across three iterative rounds of scoring across 135 statements grouped into five domains: credentialing, indications, approach, procedural factors, and safety measures. Consensus was achieved for 94 (70%) of 135 statements. The least invasive route—typically percutaneous—should be prioritised, and margin adequacy was reaffirmed as the principal technical goal. Procedural difficulty was considered context-dependent, shaped by tumour factors, institutional infrastructure, and operator experience. Organ displacement techniques were endorsed to maintain safety and expand treatable indications. Complex ablations should be done by experienced operators (more than 100 previous cases), with programmes underpinned by structured training, multidisciplinary team participation, and routine audit. Future efforts should develop and validate practical tools such as difficulty scoring systems, standardised procedural reporting templates, and comprehensive training curricula to improve consistency, standardisation, and clinical outcomes globally.

Objectives To perform the first-in-human concomitant robotic liver resection and cone-beam CT (CBCT)-guided ablation in a hybrid operating room (HARMONY). Design IDEAL stage 0/1 study outlining the preparatory steps and outcomes of the first-in-human HARMONY procedure. IDEAL stage 0 involved conceptualisation, team training and dry runs. The first HARMONY procedure was performed and the procedural technique is described in detail. Setting All procedures took place at a single academic medical centre. Participants Patients eligible for the HARMONY procedure are any adults eligible for combined ablation and resection of colorectal liver metastases. The HARMONY procedure was performed in a first patient. Outcomes of patients who underwent sequential robotic liver resection and CT hepatic arteriography-guided liver ablation in the preparatory phase are also reported. Intervention Concomitant robotic liver resection and CBCT-guided ablation in a hybrid operating room. Main outcome measures The primary outcome was technical feasibility of the HARMONY procedure defined as the technical success of both the robotic surgical resection and CBCT-guided ablation within the hybrid operating room. Results Between 2018 and 2024, 19 patients underwent sequential robotic liver resection and CT-guided ablation. Median interval between procedures was 4 days, with 36.8% treated during one admission. Intraoperative incidents occurred in three (15.8%) patients and two (10.5%) patients experienced severe complications requiring reintervention. The first-in-human HARMONY procedure was successfully completed without intraoperative complications. Conclusions The concomitant performance of robotic liver resection and CBCT-guided ablation is technically feasible in a hybrid operating room. Future studies should evaluate its reproducibility, safety and long-term outcomes. Trial registration number CCMO Research with human participants (NL-009169).

99mTc-macroaggregated albumin (MAA) imaging is part of the standard work-up procedure for radioembolization using 90Y microspheres. In certain scenarios, it may be warranted to visualize the distribution of 99mTc in co-presence of 90Y, for example when validating intra-procedural 99mTc-MAA imaging after 90Y-therapy to enable single-session radioembolization. Another instance involves additional 99mTc-MAA administration during the therapeutic procedure itself, e.g. when initial imaging reveals insufficient targeting of a specific liver segment. In these situations, crosstalk from 90Y can result in reduced 99mTc image quality and quantitative accuracy. This study investigates the feasibility and optimal method of 99mTc SPECT imaging from combined 99mTc+90Y data using phantom experiments. An anthropomorphic torso phantom with two liver tumor inserts was filled with 99mTc without (single-isotope) and with 90Y (dual-isotope) in various activities and isotope concentrations. Three collimators (low energy high resolution: LEHR, medium energy: ME, and high energy: HE) and three methods to compensate for 90Y crosstalk in the 99mTc photo peak window (Monte Carlo-based, dual-energy-window and triple-energy-window correction) were evaluated. No substantial dead-time effects were observed in the clinically relevant activity range, up to approximately 12 GBq 99mTc+90Y (ratio 1:20) with LEHR, 29 GBq with ME and > 30 GBq with HE. Compared to the clinical standard (single-isotope 99mTc imaging with LEHR collimator), contrast recovery typically decreased from 70.0 ± 1.3

We present a technique that combines Renal arteriography with C-arm CT-Guided Ablation (RenACAGA) to improve tumor visualization, navigation and margin confirmation for percutaneous ablation of renal tumors. The RenACAGA technique was used for thermal ablation of challenging renal tumors (intraparenchymal or US-occult lesions). All patients treated with RenACAGA between January 1, 2022, and July 1, 2024, were retrospectively evaluated. Procedures were performed in the angiography suite, with catheterization of the renal artery for selective contrast infusion. C-arm CT and guidance software were used for tumor visualization and ablation needle placement. Pre- and post-ablation C-arm CTs were fused to assess ablation margins. Technical success and local tumor recurrence (LTR) rate were evaluated. Complications were graded according to the Common terminology criteria for adverse events (CTCAE) version 5.0. Seven patients with 10 tumors were treated using the RenACAGA technique. All tumors were successfully identified, punctured and ablated (technical success 100

A tumor diameter > 3 cm is considered a relative contraindication for thermal ablation due to a significant risk of post-ablation recurrence. However, current advanced ablation techniques might allow for successful ablation of larger tumors. This study aimed to evaluate the impact of tumor size on outcomes of Hepatic Arteriography and C-Arm CT-Guided Ablation (HepACAGA). Patients treated with HepACAGA for hepatocellular carcinoma (HCC) or colorectal liver metastases (CRLM) between January 2021 and June 2025 were analyzed. All ablations were performed with microwave ablation. Patients were stratified by tumor size: ≤ 2 cm, 2–3 cm, and 3–5 cm. Outcomes assessed included local tumor progression-free survival (LTPFS), local tumor progression (LTP) rate, and complications. A total of 137 consecutive patients with 265 tumors (152 HCC and 113 CRLM) were included: 187 tumors ≤ 2 cm, 52 tumors 2–3 cm, and 26 tumors 3–5 cm. The 1-year LTPFS was most favorable for tumors ≤ 2 cm (96

To evaluate the safety and feasibility of intra-arterial 177Lu-PSMA-radioligand therapy (RLT) in patients with liver-dominant metastatic castration-resistant prostate cancer (mCRPC). Patients received up to six cycles of 177Lu-PSMA-RLT (median 7.4 GBq) at six-week intervals. Intra-arterial administration in the hepatic artery was off-label and indicated for patients with high hepatic tumour burden. Primary endpoints were safety (clinical and biochemical adverse events) and procedural feasibility. Exploratory efficacy endpoints were prostate-specific antigen (PSA) response and imaging (PET) response. Four patients received 16 cycles (10 intra-arterial, six intravenous). All intra-arterial procedures were technically successful and without periprocedural complications. Toxicity was acceptable and comparable to intravenous treatment, comprising mainly grade 1–2 clinical events with occasional grade 3 biochemical abnormalities, and no grade 4–5 clinical toxicities were observed. PSA decreases occurred in two patients (decrease 24–99

To study the feasibility of hepatobiliary scintigraphy (HBS) to improve selection and planning of patients with hepatocellular carcinoma (HCC) treated with holmium-166 (166Ho)-microspheres radioembolization. Thirty-one patients with HCC were included and treated with 166Ho- radioembolization as part of a prospective phase 2 study. Twenty-seven patients were eligible for analysis, 67 https://clinicaltrials.gov/study/NCT03379844?cond=hcc term=hepar primary rank=1#study-overview .

Effect of radiation on [18F]FDG-uptake in non-tumorous liver tissue after radioembolization is sparsely investigated, despite the liver being the most common reference for assessment of metabolic response (e.g., PET Response Criteria In Solid Tumors). The study aims to evaluate changes in mean standardized uptake value corrected for lean body mass in treated and untreated non-tumorous liver after unilobar radioembolization with 90Y-glass microspheres in patients with colorectal liver metastases. Eighteen patients were included. Median mean standardized uptake value corrected for lean body mass in the treated lobe increased from baseline 2.88 (range 2.24–3.81) to posttreatment 2.98 (range 2.53–3.53). In the untreated lobe, the median mean standardized uptake value corrected for lean body mass changed from 2.95 (range 2.23–4.02) to 2.88 (range 2.39–3.71), respectively. The median mean standardized uptake value corrected for lean body mass of the ratio treated/untreated liver changed from 0.96 (range .77–1.23) to 1.00 (range .88–1.26) after treatment (p = 0.147)). The correlation for the ratio (mean standardized uptake value corrected for lean body mass in treated liver divided by mean standardized uptake value corrected for lean body mass in untreated liver) before and after radioembolization was nonsignificant. No trend was seen between [18F]FDG-uptake and treated or untreated non-tumorous liver absorbed dose. This study shows no significant increase in [18F]FDG-uptake in both treated and untreated non-tumorous liver in patients with liver metastases of colorectal carcinoma, three months after lobar 90Y-glass microsphere radioembolization. This non-significant increase suggests that using background SUL in the non-tumorous liver (treated and untreated) is reliable and appropriate as a reference to assess metabolic response three months after unilobar radioembolization.