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)

Sep 29, 2026

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% treated with a staged multimodal protocol combining arterioportal fistula embolization, drug-eluting bead TACE, and systemic therapy. The strategy reduced HPS to 7.4%, enabling curative-intent Y90-SIRT; marked tumor regression allowed R0 resection, with no recurrence or complications during 6-month surveillance.

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Introduction

Case presentation

Radiology Ca s e Reports 21 (2026) 1099 – 1103 Available online [at](at www.sciencedirect.com)[ www.sciencedirect.com](at www.sciencedirect.com) journal [homepage:](homepage: www.elsevier.com/locate/radcr)[ www.elsevier.com/locate/radcr](homepage: www.elsevier.com/locate/radcr) | Case Report
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) ✩,✩✩
YaDing Luo, MD, YinSheng Lin, PhD∗
Department of Interventional Vascular Surgery, First Affiliated Hospital of Jinan University, No. 613, Huangpu Avenue, Tianhe District, Guangzhou, Guangdong Province, China | | | | --- | --- | --- | | a r t i c l e i n f o | | a b s t r a c t | | Article history:
Received 19 August 2025 Revised 4 November 2025 Accepted 5 November 2025 | | 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.
© 2025 Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license
([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/)) | | Keywords:
Hepatocellular carcinoma Hepatopulmonary shunt Yttrium-90 selective internal radiation therapy Multimodal therapy Conversion therapy | | | ✩ Competing Interests: The authors have declared that no competing interests exist. The author is an Editorial Board Member/Editorin-Chief/Associate Editor/Guest Editor for this journal and was not involved in the editorial review or the decision to publish this article.✩✩ Acknowledgments: None. This work was supported by the Guangdong Precision Medicine Application Association, the National Natural Science Foundation of China (Grant No. 62335010), the Science and Technology Projects in Guangzhou (Grant No. 2024A03J1044), and the Central Universities Fundamental Research Funds Cultivation Project (Grant No. 21624401) . The authors gratefully acknowledge the above organizations for their financial support and assistance. ∗ Corresponding author. E-mail address: [3191802694@qq.com](3191802694@qq.com) (Y. Lin). [https://doi.org/10.1016/j.radcr.2025.11.007](https://doi.org/10.1016/j.radcr.2025.11.007) 1930-0433/© 2025 Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license ([http://creativecommons.org/licenses/by-nc-nd/4.0/](http://creativecommons.org/licenses/by-nc-nd/4.0/)) Introduction Y90-SIRT provides significant local control advantages for unresectable HCC, particularly in patients with portal vein invasion [1] . Elevated HPS greater than 20% constitutes a strict contraindication to Y90-SIRT, primarily due to the risk of fatal radiation pneumonitis [2] . Current evidence supports various approaches to mitigate elevated HPS, including transarterial chemoembolization (TACE) [3], anti-angiogenic agents [4], temporary balloon occlusion [5], and

FAQs

Why is an elevated hepatopulmonary shunt (HPS) a contraindication for Y90-SIRT?

Elevated HPS above 20% is considered a strict contraindication because it increases the risk of fatal radiation pneumonitis.

What staged multimodal strategy was used to reduce prohibitive HPS in this case?

The protocol combined arterioportal fistula embolization, drug-eluting bead transarterial chemoembolization (TACE), and systemic therapy over about 4 months.

How did the treatment enable curative-intent Y90-SIRT and successful resection?

The staged strategy reduced HPS from 21.8% to 7.4%, which permitted curative-intent Y90-SIRT; subsequent tumor regression enabled an R0 resection with negative margins.

Sep 29, 2026

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