Evolving Strategies in the Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Narrative Review of Locoregional and Surgical Therapies.

This narrative review aims to provide a comprehensive, chronological evaluation of current and emerging treatment strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT), with a particular focus on the evolving role of locoregional therapies. Although PVTT is historically associated with poor prognosis and limited therapeutic options, advancements in systemic, surgical, and locoregional interventions have expanded the treatment landscape. The methodology involved a structured literature search using PubMed with therapy-specific keywords, supplemented by targeted queries in Open Evidence to identify relevant clinical trials and meta-analyses. Studies were organized in chronological order to reflect the evolution of therapeutic strategies. Systemic therapies, including tyrosine kinase inhibitors and immune checkpoint inhibitors, have shown steady improvements in overall survival (OS). Recent trials combining agents such as atezolizumab and bevacizumab have pushed median OS beyond 19 months. Locoregional therapies such as transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) have demonstrated survival benefits in selected PVTT cases, particularly when PVTT is limited to segmental or lobar branches. Combining TACE or TARE with systemic therapies further improves outcomes, with studies reporting higher objective response rates and extended progression-free survival. Surgical resection remains feasible in patients with preserved liver function and limited PVTT (Vp1-Vp2), with several studies and meta-analyses confirming superior OS compared to nonsurgical approaches. Moreover, liver transplantation, particularly after successful downstaging, has emerged as a potential curative option in highly selected patients, achieving 5-year survival rates above 60%. These findings highlight the importance of personalized, multidisciplinary treatment strategies in managing HCC with PVTT.