Transarterial chemoembolization, or TACE, is a catheter-based procedure that exploits a crucial vulnerability of liver tumors: they feed almost exclusively on the hepatic artery. During TACE, an interventional radiologist threads a microcatheter through the femoral artery into the vessels supplying the tumor, injects a concentrated dose of chemotherapy mixed with iodized oil, and then blocks the feeding artery with embolization particles. The technique traps high drug concentrations inside the tumor while cutting off its blood supply and sparing the rest of the body from systemic exposure. TACE has become a mainstay for primary liver cancer and an option for chemotherapy-refractory metastases, but the pharmacologic arsenal used inside the procedure has barely changed in decades, still relying on combinations of antimetabolites, antitumor antibiotics, and platinum compounds.

That stagnation is what motivated the new study. Paclitaxel, a taxane that poisons cancer cells by stabilizing their microtubules, is a cornerstone of breast cancer treatment, improving response rates and survival in both early and metastatic disease. Yet its conventional formulation requires a solvent that triggers hypersensitivity reactions and forms micelles in the bloodstream that interfere with drug delivery. Nab-paclitaxel sidesteps these problems by binding paclitaxel to human albumin nanoparticles, eliminating the solvent entirely. The albumin shell is more than a passive carrier: it exploits the cell’s natural transcytosis machinery, ferrying the drug across the tumor’s endothelial lining and boosting accumulation inside the tumor. In systemic therapy, nab-paclitaxel has outperformed solvent-based paclitaxel in metastatic breast cancer, and the landmark GeparSepto trial found nearly double the pathologic complete response rate in triple-negative patients treated with the nanoparticle formulation.

The researchers, led by Hamidreza Rouientan and Shahram Akhlaghpoor of the Pardis Noor Medical Imaging and Cancer Center in Tehran, reasoned that if nab-paclitaxel works better as an intravenous drug, it might work even better when injected directly into the tumor’s arterial supply. Their retrospective cohort study enrolled 59 patients treated for breast cancer liver metastases between June 2017 and June 2021. Thirty patients received TACE with 100 milligrams of nab-paclitaxel injected through the tumor-feeding microcatheter, immediately followed by the standard emulsion of carboplatin, mitomycin, and idarubicin mixed with iodized oil and gelatin sponge particles. Twenty-nine matched control patients underwent conventional TACE with the standard cocktail alone. All procedures were performed by a single interventional radiologist with 25 years of experience in hepatic interventions, and tumor response was assessed by an independent radiologist blinded to survival data using the RECIST 1.1 criteria.

The results on local tumor control were striking. Disease control, which combines complete response, partial response, and stable disease, was achieved in 93.3 percent of patients in the nab-paclitaxel group, compared with just 62.1 percent of those receiving conventional TACE, a difference that reached statistical significance. Most dramatic of all was the divergence in tumor progression: only 6.7 percent of nab-paclitaxel patients experienced progressive disease, versus 37.9 percent in the conventional group. The objective response rate, encompassing complete and partial responses, was 60 percent with nab-paclitaxel versus 44.8 percent with conventional TACE, and complete responses were more than three times as common in the nanoparticle group, though these latter differences did not reach statistical significance in the small sample. Multivariable analysis confirmed the pattern, showing that nab-paclitaxel significantly reduced the odds of progressive disease relative to stable disease.

Survival, however, told a more nuanced story. At the data cutoff, the overall survival rate for the entire cohort was 45.3 percent, and there were no statistically significant differences between the two treatment groups at the 6-, 12-, 18-, and 24-month marks. When the researchers applied inverse-probability weighting to adjust for confounding factors such as tumor burden, liver function, and hormone receptor status, the nab-paclitaxel group showed a mean survival advantage of 1.18 years, but the difference was not statistically significant. The study did identify one powerful prognostic factor: patients whose disease was confined to the liver had a 24-month survival rate of 60.6 percent, compared with just 30.8 percent for those with extrahepatic metastases, and liver-only disease was associated with roughly half the risk of death.

Safety findings were reassuring. No treatment-related deaths occurred, and adverse events were recorded at nearly identical rates in both groups, 50 percent after nab-paclitaxel TACE and 58.6 percent after conventional TACE. The most common complaints were abdominal pain, nausea, and fatigue, symptoms that typically lasted two to seven days and resolved with supportive care. This stands in contrast to systemic nab-paclitaxel, whose side effects include myelosuppression, alopecia, and sensory neuropathy. The authors argue that intra-arterial delivery is precisely the point: by concentrating the drug where the tumor lives, the approach achieves higher local doses with lower total drug amounts and minimal exposure of healthy tissue, potentially allowing more frequent treatment sessions than systemic chemotherapy would tolerate.

The findings fit into a broader effort to modernize the drug regimens used in liver-directed therapy. Previous studies have tested additions to the TACE cocktail, with mixed results. One German group found that adding gemcitabine to mitomycin modestly reduced progressive disease from 38.2 percent to 33 percent in breast cancer liver metastases. Other trials of gemcitabine-based TACE and doxorubicin-loaded microspheres reported disease control rates ranging from 44 to 83 percent. Against this backdrop, the 93.3 percent disease control rate and the near-elimination of progressive disease in the nab-paclitaxel group stand out, even allowing for the caveats of retrospective comparison. The authors suggest that the drug’s albumin-mediated uptake mechanism may be particularly well suited to the tumor biology that TACE creates, where embolization-induced hypoxia and the enhanced permeability of tumor vessels favor nanoparticle accumulation.

The study’s limitations are real and the authors acknowledge them candidly. The retrospective design, the single-center setting, and the modest sample size of 59 patients all constrain the strength of the conclusions, and the nab-paclitaxel group was treated as part of an evolving multidisciplinary strategy rather than a randomized protocol. Selection bias was mitigated but not eliminated by matching and statistical weighting. Larger prospective randomized trials with extended follow-up will be needed to determine whether the impressive local control translates into a survival benefit, and the authors suggest that precision medicine approaches, incorporating molecular profiling of individual tumors, may eventually identify which patients stand to gain the most from the nanoparticle formulation.

Even with those caveats, the message is provocative. For a patient population whose median survival is measured in months and whose treatment options narrow quickly after chemotherapy failure, a technique that keeps liver tumors in check with a manageable side-effect profile is not a trivial advance. The authors conclude that incorporating nab-paclitaxel into TACE could be a reasonable treatment option for breast cancer liver metastases until proven otherwise, a carefully hedged endorsement that nonetheless signals a shift: after years of relying on the same aging drug cocktails, interventional oncology may finally be ready to update its pharmacopeia, one nanoparticle at a time.

Subject of Research: Nab-paclitaxel added to transarterial chemoembolization for breast cancer liver metastases

Article Title: Nab-paclitaxel in conventional trans arterial chemoembolization for breast cancer liver metastasis: it is time to add new drugs to TACE

Article References: Nab-paclitaxel in conventional trans arterial chemoembolization for breast cancer liver metastasis: it is time to add new drugs to TACE. (n.d.). https://doi.org/10.1007/s44343-025-00006-2

Image Credits: AI Generated

DOI: 10.1007/s44343-025-00006-2

Keywords: breast cancer, liver metastases, transarterial chemoembolization, nab-paclitaxel, interventional radiology, interventional oncology, chemotherapy, drug delivery, RECIST, tumor response, nanoparticles, locoregional therapy

A new single-center retrospective study published in the European Journal of Nuclear Medicine and Molecular Imaging aims to change that. Researchers at Beijing Tsinghua Changgung Hospital analyzed 290 consecutive patients with unresectable hepatocellular carcinoma who underwent yttrium-90 selective internal radiation therapy between October 2022 and December 2025. Among them, 91 were flagged on pre-treatment imaging as potentially receiving tumor blood flow from the inferior phrenic artery, and 78 ultimately had angiographically confirmed supply from that vessel. The team then compared the two main ways interventional radiologists handle the artery: threading microspheres directly through it into the tumor, or deliberately plugging it with coils so that tumor blood flow is redirected back into the liver’s own arterial network.

The technical foundation of the study lies in meticulous pre-procedural mapping. Every patient underwent hepatic digital subtraction angiography combined with cone-beam computed tomography, a pairing that allows physicians to see not just the two-dimensional course of the vessels but the full three-dimensional territory each artery perfuses. A technetium-99m macroaggregated albumin injection followed by SPECT/CT simulation calculated the lung shunt fraction, ensuring that too many microspheres would not escape to the lungs, and post-treatment PET/CT verified where the radioactive spheres actually landed. Using a 2.1 French goose-neck microcatheter, the team achieved superselective catheterization of the inferior phrenic artery in 88.6 percent of attempted cases, demonstrating that even this small, tortuous vessel can be reliably accessed when combined angiographic and tomographic guidance is used.

The decision-making algorithm the researchers propose hinges on two variables: the volume of tumor fed by the inferior phrenic artery and the anatomy of any non-target branches that could carry microspheres into dangerous territory. When the artery perfused at least 20 milliliters of tumor and risky branches could be managed, the team favored direct infusion of yttrium-90 microspheres through the vessel, reserving prophylactic coil embolization for high-risk offshoots such as suprarenal, esophageal, pericardial, or pulmonary shunt branches. When the perfused tumor volume fell below 20 milliliters or non-target vessels could not be safely catheterized, the team simply embolized the artery trunk with coils, wagering that intrahepatic arteries would compensate. Forty-five patients landed in the infusion group and 33 in the embolization group, with the infusion cohort predictably carrying heavier tumor burdens and more advanced disease.

The anatomical findings reinforce how distinctive the inferior phrenic artery can be. The right inferior phrenic artery dominated as the parasitic feeding vessel in 89.8 percent of cases, with the left artery accounting for only 7.7 percent and dual supply appearing in 2.5 percent. Most of these arteries originated from the celiac trunk or directly from the abdominal aorta, though a striking 21.8 percent arose from the renal artery. The median radioactivity delivered through the inferior phrenic artery was a modest 0.3 gigabecquerels, yet the dosimetric payoff was substantial: the median tumor-absorbed dose in the infusion group reached 92 Gy, with three-quarters of those patients receiving at least 61 Gy, approaching the 100 to 250 Gy window widely recommended for hepatocellular carcinoma.

Perhaps the most eye-catching result concerns the embolization strategy, which has always rested on an assumption that had never been carefully quantified. If you plug the parasitic artery, does tumor blood flow really reroute to intrahepatic vessels in time to matter? By comparing intra-procedural cone-beam CT with post-treatment PET/CT, the researchers found that approximately 88 percent of the territory originally supplied by the inferior phrenic artery received yttrium-90 microspheres through compensatory intrahepatic pathways, with more than half of lesions achieving complete hemodynamic compensation. Critically, the compensatory rate held steady regardless of tumor size, suggesting that flow redistribution after coil embolization is a robust phenomenon rather than a fortunate accident, and providing quantitative reassurance comparable to the 83.8 percent redistribution rate previously reported with glue embolization.

On efficacy, direct infusion through the inferior phrenic artery consistently outperformed embolization. Using the modified Response Evaluation Criteria in Solid Tumors, the objective response rate in the infusion group climbed from 60.0 percent at one month to 82.3 percent at three months, whereas the embolization group moved from 48.5 percent to 69.7 percent over the same intervals. The gap between the groups widened to 12.6 percentage points by three months, and the complete response rate in the infusion group surged from 17.8 percent to 46.7 percent, an absolute gain of 28.9 percentage points that far outpaced the 21.2 percent rise seen in the embolization cohort. Disease control rates exceeded 93 percent at one month in both groups, underscoring that neither strategy leaves patients behind.

Safety is where lingering fears about extrahepatic radiation have historically been most vocal, and the study directly confronts them. Mean whole-lung absorbed dose was 9.53 Gy, comfortably below the 20 Gy clinical threshold, with no significant differences between groups in lung volume, lung shunt fraction, or lung dose. The overall adverse event rate was 17.8 percent in the infusion group and 9.1 percent in the embolization group, a difference that was not statistically significant, and every reported event was a mild to moderate, reversible thoracic complaint. No severe treatment-related complications occurred in either arm, an outcome the authors attribute to the discipline of combined DSA-CBCT anatomical evaluation paired with prophylactic embolization of non-target branches whenever they were visualized.

The study’s authors are candid about its limits. As a single-center retrospective analysis, it carries inherent selection bias, and the infusion group’s higher tumor burden and greater proportion of Barcelona Clinic Liver Cancer stage C patients may confound the efficacy comparison. Only three-month tumor response was assessed, leaving progression-free survival and overall survival unmeasured, and the team calls for long-term follow-up and multicenter prospective validation before the algorithm becomes standard practice. Even so, the work represents the largest head-to-head comparison of inferior phrenic artery strategies in yttrium-90 radioembolization to date, and it delivers something the field has lacked: a concrete, volume-based decision rule. Direct infusion when the artery feeds at least 20 milliliters of tumor and the plumbing cooperates; embolization when it does not. For the roughly one in three hepatocellular carcinoma patients whose tumors recruit this diaphragmatic artery, that clarity could mean the difference between an incomplete treatment and a truly definitive one.

Subject of Research: Inferior phrenic artery management strategies during yttrium-90 selective internal radiation therapy for hepatocellular carcinoma.

Article Title: Interventional strategies for inferior phrenic artery management in yttrium‑90 selective internal radiation therapy for hepatocellular carcinoma: A single‑center retrospective study

Article References: Liao, Y., Huang, X., Liang, Z., Ma, J., Feng, X., Fu, W., Liang, B., Yang, S., Li, G., Bao, L., Zhang, T., Zheng, L., Liu, C., Tang, M., Zhang, L., & Dong, J. (2026). Interventional strategies for inferior phrenic artery management in yttrium‑90 selective internal radiation therapy for hepatocellular carcinoma: A single‑center retrospective study. European Journal of Nuclear Medicine and Molecular Imaging. https://doi.org/10.1007/s00259-026-08170-0

Image Credits: AI Generated

DOI: 10.1007/s00259-026-08170-0

Keywords: yttrium-90, selective internal radiation therapy, hepatocellular carcinoma, inferior phrenic artery, radioembolization, interventional radiology, cone-beam computed tomography, lung shunt fraction, mRECIST, extrahepatic collateral supply, tumor response, coil embolization

The technique is a hybrid of two established concepts in interventional radiology. Radiation segmentectomy delivers an ablative dose of yttrium-90 glass microspheres directly into the artery feeding the tumor, achieving intense local tumor control. Radiation lobectomy, by contrast, treats the entire tumor-bearing lobe with a moderate dose that induces atrophy of the treated parenchyma, redirecting portal blood flow and growth signals to the untreated lobe, which compensates by enlarging. Modified radiation lobectomy combines these effects in a single procedure: a segmental or two-adjacent-segment boost above 190 Gy for tumor control, layered onto a lobar dose between 80 and 120 Gy to drive hypertrophy of the future liver remnant. In this study, the mean lobar prescribed dose was 198 plus or minus 58 Gy, with a mean segmental boost of 226 plus or minus 153 Gy, and patients received an average of 1.6 segmental doses.

The standard alternative for expanding a future liver remnant is portal vein embolization, which reliably induces hypertrophy but offers no direct tumor treatment, leaving a window during which cancer can progress. Transarterial chemoembolization controls tumors but produces less predictable liver growth and typically requires staged procedures. Modified radiation lobectomy uniquely merges tumor control and remnant augmentation in one session, which is why the researchers at an academic medical center in Colorado turned to it for patients whose tumors were unresectable by imaging criteria or biopsy, who had preserved liver function classified as Child-Pugh A, an Eastern Cooperative Oncology Group performance status of two or less, satisfactory lung shunt fractions, and no extrahepatic disease.

Between January 2019 and April 2022, fifteen consecutive patients underwent the procedure with the intention of bridging to curative resection. The cohort included seven women and eight men with a mean age of 66 years, ranging from 41 to 84. Seven had hepatocellular carcinoma, six of them at intermediate BCLC stage B and one at advanced stage C with portal vein tumor invasion, while eight had intrahepatic cholangiocarcinoma, five of whom had also received neoadjuvant gemcitabine-cisplatin chemotherapy. The mean index tumor size was a formidable 7.8 centimeters, with the largest measuring 16.2 centimeters. All patients had preserved hepatic function, and seven had underlying liver disease, including hepatitis C, alcohol-related injury, and metabolic dysfunction-associated steatotic liver disease.

Treatment planning was individualized through multidisciplinary tumor board discussion and surgical volumetric assessment. Earlier patients underwent planar macroaggregated albumin dosimetry with single-compartment calculations, while later patients benefited from SPECT/CT-based multicompartment personalized dosimetry using dedicated software. In that subgroup, the average perfused tumor absorbed dose reached 576 plus or minus 284 Gy, the average normal tissue dose was 206 plus or minus 95 Gy, the perfused fraction of the liver averaged 63 percent, and the cumulative lung absorbed dose averaged 16.4 Gy. Follow-up with triphasic CT or MRI occurred at one and three months and then at three-month intervals, with volumetric analysis at every time point using the Couinaud methodology and standardized future liver remnant calculations based on body surface area.

The results were remarkable on both fronts. Every one of the fifteen patients showed an objective tumor response by modified RECIST criteria at thirty days, with 40 percent achieving a complete response and 60 percent a partial response; by ninety days, the complete response rate rose to 53 percent as two additional partial responders converted. Meanwhile, the median future liver remnant increased by 12 percent at thirty days and 30 percent at sixty to ninety days. Median standardized future liver remnant climbed from 31 percent at baseline to 36 percent at one month and 40 percent by two to three months. Notably, hypertrophy was similar in cirrhotic and non-cirrhotic patients, and no difference emerged between hepatocellular carcinoma and cholangiocarcinoma, suggesting the volumetric effect is robust across liver conditions and tumor types.

Safety was equally encouraging. There were no major procedure-related complications, no grade three or higher hepatotoxicity by CTCAE version 5.0 criteria, and no cases of cholangitis, cholecystitis, gastric ulcers, pneumonitis, or radiation-induced liver disease. One patient experienced nausea and vomiting lasting ten days, and no patient required extended hospitalization or readmission within thirty days. This favorable profile likely reflects careful selection of patients with preserved baseline liver function and multidisciplinary evaluation, consistent with prior work showing that yttrium-90 treatment of more than 60 percent of the liver can be safe when an adequate functional remnant is maintained.

The surgical conversion rate was the standout finding. Twelve of the fifteen patients, or 80 percent, became technically eligible for curative-intent surgery, a figure substantially higher than the 16 to 20 percent conversion rates reported in earlier modified radiation lobectomy studies. Three patients were excluded by new disease progression in the contralateral liver or lungs, or inadequate remnant growth. Of the twelve eligible patients, one declined surgery and one resection was aborted because cholangiocarcinoma encased the hepatic vein confluence. Ultimately, ten patients underwent major hepatectomy, including four extended right and four standard right hepatectomies and one extended left hepatectomy, or liver transplantation in one case, at a mean of 122 plus or minus 77 days after radioembolization. Every completed resection achieved negative margins, an R0 outcome that is the surgical gold standard.

Pathology revealed a more nuanced picture. Among eight patients with available data, median tumor necrosis was 57.5 percent, ranging from 30 percent to more than 90 percent, and necrosis did not correlate with imaging response or absorbed dose. The authors attribute this variability to large, heterogeneous tumors with uneven microsphere distribution and to the relatively short interval between treatment and explantation. Despite this, overall survival after surgery remained 80 percent. Two patients with cholangiocarcinoma died within days of surgery from infectious complications, while the remaining eight resected patients showed no evidence of recurrence over an average follow-up of 39 months. Median overall survival was 61 months for hepatocellular carcinoma patients but only 19 months for those with cholangiocarcinoma, underscoring that tumor biology, not technical success, remains the dominant determinant of long-term outcome.

The study has clear limitations: it was retrospective, single-center, and small, with heterogeneous dosimetry methods and no comparator group receiving portal vein embolization or chemoembolization. Yet the message is compelling. Modified radiation lobectomy achieved universal tumor response, meaningful remnant hypertrophy, and an 80 percent surgical eligibility rate in patients whose tumors were once deemed unresectable, all with an excellent safety profile. The findings echo larger evidence, including the updated DOSISPHERE-01 analysis and the prospective PROACTIF cohort, showing that patients who reach curative surgery after yttrium-90 therapy enjoy substantially better survival than those managed nonoperatively. Larger prospective trials comparing modified radiation lobectomy with established bridging strategies are still needed, but for carefully selected patients with large primary liver cancers, this single-procedure approach may be transforming the boundary between inoperable and curable.

Subject of Research: Modified yttrium-90 radiation lobectomy as a bridge to curative surgery for primary liver cancer

Article Title: Modified radiation lobectomy as a bridge to curative surgery: tumor response, future liver remnant hypertrophy, and surgical outcomes

Article References: Malavia, M., Lindquist, J., Marchak, K., Eliason, G., Trivedi, P., & Casadaban, L. (2026). Modified radiation lobectomy as a bridge to curative surgery: tumor response, future liver remnant hypertrophy, and surgical outcomes. CVIR Oncology, 2(1), Article 29. https://doi.org/10.1007/s44343-026-00059-x

Image Credits: AI Generated

DOI: 10.1007/s44343-026-00059-x

Keywords: modified radiation lobectomy, yttrium-90 radioembolization, hepatocellular carcinoma, intrahepatic cholangiocarcinoma, future liver remnant hypertrophy, liver resection, radiation segmentectomy, portal vein embolization, surgical conversion, tumor response, interventional radiology, liver cancer