Y-90 Radioembolization in Hepatocellular Carcinoma: Expanding the Role of Interventional Oncology in Downstaging and Bridging to Liver Transplantation

Abstract 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.