Kirema Garcia-Reyes

1. Hepatocellular carcinoma (HCC) is the most common form of liver cancer and represents a major global health concern [1]. In the United States, an estimated 42,240 new liver cancer cases and appr...

Objective: To establish the significance of complete pathologic response (cPR) on survival and locoregional treatment outcomes in a large US cohort. Background: cPR in hepatocellular carcinoma (HCC) is associated with improved post–liver transplant (LT) outcomes. cPR rates, modality-specific differences, and predictors remain undefined. Materials and Methods: Patients were identified from the United Network for Organ Sharing (UNOS) database (2012–2024). cPR was defined as the absence of a viable tumor on explant pathology. Logistic regression identified predictors of cPR, Fine-Gray models estimated the incidence of cPRand Kaplan-Meier analysis assessed survival. Results: Among 7398 LT recipients, 2167 (29.3%) achieved cPR. Imaging–pathology concordance was poor (30.5%), with imaging overestimating response in 42.6% of cases (κ=0.17, P 18 vs. P P <0.001). Conclusions: Nearly one-third of LT recipients with HCC achieved cPR, which was associated with improved survival. Y-90 was independently associated with higher cPR rates, particularly when administered early and among patients with higher tumor burden.

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.

BACKGROUND: Recent observational studies have suggested that early treatment (P =0.071). Mean pulmonary artery pressure decreased significantly more in patients receiving early thrombectomy (8.6±5.2 versus 5.8±5.0 mm Hg; P =0.006). The major adverse events rate was similar ( P =0.431) between groups, and there were no mortalities. The differences in efficacy outcomes were greatest in higher-risk patients per the Composite Pulmonary Embolism Shock score. CONCLUSIONS: Early mechanical thrombectomy was associated with larger reductions in right ventricle–to–left ventricle ratio and mean pulmonary artery pressure, with no significant differences in safety event rates compared with patients who underwent late thrombectomy. Randomized trials are needed to test these associations. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06062329.

Transarterial radioembolization (TARE) with Yttrium-90 (Y-90) is increasingly utilized as a first-line modality in the management of hepatocellular carcinoma, offering effective local tumor control with favorable toxicity profiles. While traditionally viewed as palliative, accumulating evidence supports its use as curative intent therapy and in bridging or downstaging patients to transplant. This review explores the expanding role of Y-90 in downstaging patients beyond transplant criteria and in bridging those already eligible. We highlight the outcomes from pivotal studies, including LEGACY and DOSISPHERE-01, which demonstrate high rates of sustained tumor response, low transplant list dropout, and excellent posttransplant survival—especially when TARE is delivered segmentally and with personalized dosimetry. Y-90's ability to preserve hepatic function and achieve superior local control in larger tumors makes it particularly well-suited to the transplant population. We compare Y-90 with transarterial chemoembolization, addressing key distinctions in efficacy, durability, and tolerability. Practical considerations—including patient selection, treatment planning, transplant timing, and multidisciplinary coordination—are reviewed. Finally, we discuss future directions, including the role of Y-90 in combination with immunotherapy and ongoing prospective transplant-centered trials.

Transarterial radioembolization (TARE) is an established therapy for primary and secondary hepatic malignancies. Outcomes depend heavily on dosimetry, which has evolved from empirical and body-surface-area methods to partition and voxel-based approaches. This review summarizes current evidence for advanced (personalized) dosimetry across tumor types, highlights emerging dose–response concepts, and outlines practical barriers and implementation strategies. A narrative review of peer-reviewed clinical studies and trials evaluating dosimetry in TARE, with emphasis on hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (iCCA), metastatic colorectal cancer (mCRC), neuroendocrine tumor (NET), and breast cancer liver metastases, was performed with comparison of single-compartment medical internal radiation dosimetry method (MIRD), partition (multicompartment) methods, and voxel-based dosimetry methodologies. Personalized dosimetry improves outcomes in multiple tumor types. A randomized trial in HCC showed superior overall survival with partition-based dosing versus MIRD. In selective HCC treatments, voxel-derived metrics (e.g., D95) correlate with complete pathologic necrosis, suggesting benefit beyond mean dose targets. For iCCA, data associate higher tumor doses with better radiologic response, progression-free survival, and downstaging. In mCRC, voxel-based and threshold analyses link specific tumor and margin doses with metabolic/radiographic response and survival. Smaller series in NET and breast cancer indicate dose–response relationships using advanced dosimetry. Evidence supports broader adoption of advanced dosimetry in TARE. Emerging strategies that ensure adequate coverage of the “coldest” tumor regions and thoughtful particle-load planning may further optimize results. Standardized protocols, prospective validation, and scalable workflows are needed to accelerate implementation.

BACKGROUND: Mechanical thrombectomy offers a promising alternative to thrombolytic-based approaches for reducing thrombus burden and right heart strain in acute pulmonary embolism. This pivotal Food and Drug Administration–approval trial evaluated the safety and efficacy of the Symphony Thrombectomy System (Imperative Care, Inc, Campbell, CA) in acute intermediate-risk pulmonary embolism. METHODS: Patients with intermediate-risk pulmonary embolism (systolic blood pressure ≥90 mm Hg; right ventricle-to-left ventricle ratio >0.9) were enrolled without roll-ins. The primary safety end point was the rate of major adverse events within 48 hours, defined as a composite of all-cause major bleeding, device-related mortality, and serious device-related events, adjudicated by an academic independent safety board. The primary efficacy end point was the core laboratory–assessed mean change in right ventricle-to-left ventricle ratio from baseline to 48 hours. Prespecified performance goals were set for both. Exploratory end points included immediate postprocedure change in mean pulmonary artery pressure and change in modified Miller index at 48 hours. Safety was assessed in the intention-to-treat cohort and efficacy in the modified intention-to-treat cohort, excluding patients receiving nonstudy device treatments. RESULTS: Between December 2023 and May 2025, 109 patients were treated at 17 US centers (intention-to-treat), with 106 in the modified intention-to-treat cohort. The major adverse events rate was 0.9% (1/109), with an upper 97.5% CI of 5.7%, meeting the P 0.20 performance goal ( P P <0.001. CONCLUSIONS: These data support the safety and effectiveness of the Symphony Thrombectomy System in patients with acute intermediate-risk pulmonary embolism. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT06062329.

Real-world outcomes in early-stage hepatocellular carcinoma (eHCC) are not well characterized. We aimed to evaluate treatment patterns and long-term outcomes in patients with eHCC treated with resection or ablation in the United States. We conducted a retrospective study with Optum's de-identified Market Clarity Data. Patient characteristics, treatment patterns, and overall survival (OS) were assessed in adults with eHCC treated with resection or ablation between July 2016 and March 2021. Of 649 patients who met inclusion criteria, 59.3%, 37.3%, and 3.4% underwent ablation only, resection only, or both, as their initial treatment, respectively. Median age was 64.0 years; most patients were male (72.9%) and White (65.5%). Subsequent treatment was received in 47.1% of patients. The median (quartile 1-3) time to first subsequent treatment was 216 (89.3-414.3) days. The most common subsequent treatments included embolization (22.7%) and ablation (15.6%). In total, 35.7% of patients died post-index. Median OS was 67.7 (95% CI: 56.4-not estimable) months. Estimated 24-month OS was 79.0% (95% CI: 75.0-82.0). Our results highlight the need for post-treatment surveillance and the potential role for neoadjuvant and/or adjuvant treatments to improve outcomes in patients with eHCC treated with resection or ablation.

Background/Objectives: Prostatic artery embolization (PAE) has been increasingly recognized, especially with recent progress in embolization techniques for the management of lower urinary tract symptoms due to benign prostatic hyperplasia. Nevertheless, a proportion of patients undergoing PAE fail to demonstrate clinical improvement. Machine learning models have the potential to provide valuable prognostic insights for patients undergoing PAE. Methods: A retrospective cohort study was performed utilizing a modified prior-data fitted network architecture to predict short-term (7 weeks) favorable outcomes, defined as a reduction greater than 9 points in the International Prostate Symptom Score (IPSS), in patients who underwent PAE with nBCA glue. Patients were stratified into two groups based on the median IPSS reduction value, and a binary classification model was developed to predict the outcome of interest. The model was developed using clinical tabular data, including both pre-procedural and intra-procedural variables. SHapley Additive ExPlanations (SHAP) were used to uncover the relative importance of features. Results: The final cohort included 109 patients. The model achieved an accuracy of 0.676, an MCC of 0.363, a precision of 0.666, a recall of 0.856, an F1-score of 0.731, and a Brier score of 0.203, with an AUPRC of 0.851 and an AUROC of 0.821. SHAP analysis identified pre-PAE IPSS, prior therapy, right embolization volume, preoperative quality of life, and age as the top five most influential features. Conclusions: Our model showed promising discrimination and calibration in predicting early outcomes of PAE with nBCA glue, highlighting the potential of precision medicine to deliver interpretable, individualized risk assessments.