Elevated baseline C-reactive protein is associated with treatment failure and shorter survival after Yttrium-90 radioembolization in hepatocellular carcinoma.

OBJECTIVE: To evaluate the impact of baseline C-reactive protein (CRP) on outcomes after yttrium-90 (Y-90) radioembolization (RE) for hepatocellular carcinoma (HCC). METHODS: This retrospective study included patients with HCC treated with Y-90 RE at a tertiary center (June 2022-June 2025). Dosimetry was based on 99mTc-MAA SPECT/CT with refined post hoc high-dose definitions. High-dose therapy was defined as tumor-absorbed dose > 250 Gy for lobar treatments (glass or resin). For segmentectomy, high dose was defined as perfused-liver absorbed dose > 400 Gy for glass and > 250 Gy for resin microspheres. Patients were stratified by baseline CRP: low (≤ 1 mg/dL) vs. high (> 1 mg/dL). Tumor response was assessed on gadoxetate-enhanced MRI using mRECIST. Local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were estimated by Kaplan-Meier and compared with log-rank tests. Cox regression identified independent prognostic factors. RESULTS: The cohort comprised 103 patients (mean age 65.8 ± 9 years; 76.7% male). BCLC stages were A (n = 27), B (n = 35), and C (n = 41); median largest tumor diameter was 6.0 cm (IQR 4.1-8.8), and median follow-up was 26 months. On multivariable analysis, CRP > 1 mg/dL independently predicted inferior LPFS (HR 3.6, p < 0.001), PFS (HR 2.7, p = 0.002), and OS (HR 4.8, p < 0.001). High-dose treatment was independently associated with improved LPFS (HR 0.55, p = 0.043) and OS (HR 0.47, p = 0.021). In subgroup analyses, high-dose treatment was associated with longer survival in the low-CRP group but not in the high-CRP group. CONCLUSION: Baseline CRP > 1 mg/dL is a strong adverse prognostic factor after Y-90 RE. High-dose RE was associated with longer survival in patients with low CRP but not in those with elevated CRP; this hypothesis-generating observation requires prospective confirmation.