A novel triple-modality approach overcoming prohibitive hepatopulmonary shunt (HPS): Enabling yttrium-90 selective internal radiation therapy (Y90-SIRT) and subsequent curative resection in massive hepatocellular carcinoma (HCC)

Elevated hepatopulmonary shunt exceeding 20% is a strict contraindication for Y90-SIRT due to the risk of fatal radiation pneumonitis, posing a significant clinical challenge in the management of such HCC cases. We report a 45-year-old man with unresectable massive HCC and an initial HPS of 21.8% who was treated with a staged multimodal protocol involving arterioportal fistula embolization, drug-eluting bead transarterial chemoembolization (TACE), and systemic therapy. This strategy successfully reduced the HPS to 7.4%, which permitted curative-intent Y90-SIRT. Subsequent significant tumor regression enabled an R0 resection-defined as complete resection with negative margins. The patient showed no evidence of recurrence or postoperative complications during 6-month surveillance. This case highlights that a strategically sequenced combination of locoregional and systemic therapies can overcome absolute contraindications to Y90-SIRT, enabling conversion to resection in selected patients with advanced HCC.