Precision liver surgery-guided anatomical yttrium-90 radiation segmentectomy with resin microspheres for hepatocellular carcinoma

For patients with early-stage hepatocellular carcinoma (HCC), radiation segmentectomy (RS) has been recognized as a curative-intent treatment option. Besides, real-world experience has suggested that RS may achieve favorable local tumor control in appropriately selected patients with large or advanced HCC. However, standardized and widely accepted procedural protocols for anatomical RS have yet to be established. We proposed an anatomical RS paradigm guided by precision liver surgery principles. Clinical, imaging, and follow-up data were retrospectively reviewed for HCC patients who underwent RS at our institution between Oct 2022 and Jun 2025. Treatment response was assessed on contrast-enhanced CT/MRI using the Liver Imaging Reporting and Data System Treatment Response Algorithm (LI-RADS TRA). Hematologic and liver function-related biochemical toxicities were graded according to the Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Time-to-progression (TTP) and overall survival (OS) were estimated using the Kaplan-Meier (K-M) method. Twenty-three HCC patients were included; 11 received RS alone (Cohort 1) and 12 received RS combined with systemic therapy (Cohort 2). The absorbed dose to target lesions was 250.0 (200.0-300.0) Gy. Among patients with tumors < 5 cm, radiation subsegmentectomy (sub-RS) was achieved in 9 of 17 (52.9%). The objective response rate (ORR) for target lesions was 100% at both 3 and 6 months. All patients were discharged uneventfully, and 87.0% (20/23) were discharged on post-procedure day 1. Grade 3 adverse events consisted of lymphopenia ( n = 7) and alanine aminotransferase elevation ( n = 1); all were considered treatment-related. The median follow-up time for the overall cohort was 18.8 months. The median TTP was 32.7 months for Cohort 2, whereas the median OS was not reached in either cohort. Precision liver surgery-guided anatomical RS using resin microspheres appears feasible and well tolerated, with favorable early tumor control in selected HCC patients.