Background. In patients with hepatocellular carcinoma, selection criteria for transarterial hepatic selective internal radiotherapy are imprecise. Additionally, radiographic parameters to predict outcome of transarterial hepatic selective internal radiotherapy have not been fully characterized. Patients and methods. Computed tomography (CT) scans of 23 patients with unresectable primary hepatocellular carcinoma before and after transarterial hepatic selective internal radiotherapy with yttrium-90 microspheres were retrospectively reviewed. Selected radiographic parameters were evaluated and correlated with progression-free survival and overall survival. Response to treatment was assessed with Response RECIST 1.1 and Morphology, Attenuation, Size, and Structure (MASS) criteria. Results. On the post-SIRT CT, 68% of tumors demonstrated decreased size (median decrease of 0.8？cm, ); 64% had decreased attenuation (median decrease 5.7？HU, ), and 48% demonstrated increased tumor necrosis ( ). RECIST-defined partial response was seen in 10% patients, stable disease in 80%, and 10% had disease progression. Median progression-free survival was 3.9 months (range, 3.3 to 7.3), and median overall survival was 11.2 months (7.1 to 31.1). Pretreatment lower hepatopulmonary shunt fraction, central hypervascularity, and well-defined tumor margins were associated with improved progression-free survival. Conclusion. In patients with unresectable hepatocellular carcinoma, pretreatment CT parameters may predict favorable response to SIRT and improve patient selection. 1. Introduction Hepatocellular carcinoma is the third leading cause of cancer mortality worldwide [1]. It frequently occurs in patients who have chronic liver disease and cirrhosis [2, 3]. Curative treatment options include liver transplant, resection, and ablation [4]. However, approximately two thirds of patients are not candidates for curative therapy when diagnosed [5]. In selected patients, transarterial chemoembolization or radioembolization may be options for palliative treatment [6–9]. For patients with advanced hepatocellular carcinoma who are not candidates for curative or liver-directed therapies, targeted molecular therapy with sorafenib may improve survival [10, 11]. In the past, hepatocellular carcinoma had been considered a radioresistant tumor because of the limited effect of external beam radiation doses. This was caused, in part, by technical limitations imposed by the overlying anatomy [12, 13]. In selective internal radiotherapy (SIRT) with yttrium-90 microspheres, radioactive particles are
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