TABLE OF CONTENT LIST OF ABBREVIATIONS I. GENERAL INTRODUCTION 1. Hepatocelluar carcinoma 1.1. Demographic data 1.2. Pathogenesis
1.3. The TNM tumor staging and the BCLC allocation system 1.4. Treatment allocation according to the BCLC algorithm
1.4.1. Concept of bridging-to-surgery 1.4.2. Concept of downstaging
2. 90Yttrium Radioembolization (Y90) and other liver directed therapies
2.1. Historical development of internal radiation techniques 2.2. Interventional oncology armamentarium
2.2.1. “Ablative” therapies 2.2.2. Transarterial therapies 2.2.3. Portal Vein Embolization
2.3. Therapeutic principles of Y90
2.3.1. Products and devices 2.3.2. Radiobiological properties
2.4. Evidence for Y90 and HCC and place of Y90 in the BCLC allocation system
3. Imaging and technical considerations
3.1. Treatment planning
3.1.1. Biological and imaging requirements
3.1.2. Simulation angiography and 99Tc-MAA scintigraphy
3.1.3. Planned activity calculation
3.2. Treatment
3.3. Administered activity calculation
4. Response assessment after Y90
4.1. General considerations on the response assessment 4.2. Enhanced CT
4.3. Magnetic resonance imaging 4.4. PET-CT
4.5. Size criteria: WHO; RECIST; and volume 4.6. “Enhancement criteria”: EASL and mRECIST 4.7. Diffusion-Weighted Imaging
4.8. Illustrative Case of MRI Patterns of Response to Y90
5. Pathological findings after Y90
5.1. Macroscopy
5.2. Microscopy
III. RAISED QUESTIONS
IV. SUMMARY OF PERSONAL INVESTIGATIONS 1. Review: New imaging techniques for Y90.
1.1. Summary
1.2. Hepatocellular carcinoma 1.3. Response assessment 1.4. Morphological changes 1.5. Diffusion-Weighted Imaging
2. Study 1: What is the biological, imaging and clinical response of solitary <5cm hepatocellular carcinoma to the Y90 Radiation Segmentectomy technique?
2.1. Introduction
2.2. Material and Methods 2.3. Results
2.4. Conclusion
3. Study 2: Radiation Lobectomy: interest as a bridge-to-resection technique?
3.1. Introduction
3.2. Material and Methods
3.3. Results
3.4. Conclusion
4. Study 3: What is the role of size, enhancement, and diffusion imaging criteria as predictors of pathological response of unresectable HCC after Y90?
4.1. Introduction
4.2. Material and Methods 4.3. Results
4.4. Conclusion
5. Study 4: Is 3D ADC response assessment useful in predicting pathological response of unresectable HCC after Y90?
5.1. Introduction
5.2. Material and Methods
5.3. Results 5.4. Conclusion V. SYNTHESIS OF RESULTS VI. DISCUSSION 1. On radiation segmentectomy 2. On radiation lobectomy 3. On the response assessment 4. Limitations of our investigations
4.1. Limitations common to study 1 and 2 4.2. Limitations of study 1
4.3. Limitations of study 2
4.6. Limitations of study 4
