Novel Strategies for the Management of Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: A Review.

Portal vein tumor thrombus (PVTT) occurs in more than half of patients with hepatocellular carcinoma (HCC) and is associated with markedly shortened survival and a poor prognosis. Historically, management relied mainly on locoregional therapies or upfront surgical resection, but outcomes remained unsatisfactory. In recent years, immune checkpoint inhibitors (ICIs) combined with antiangiogenic targeted therapy have substantially changed the systemic treatment landscape for advanced HCC and created new opportunities for patients with unresectable or borderline-resectable HCC with PVTT to undergo conversion therapy followed by sequential surgery (CT-S). This review summarizes conventional treatment strategies for HCC with PVTT; the biologic rationale and clinical evidence for the conversion therapy based on the combination of immune checkpoint inhibitors (ICIs) and anti-angiogenic targeted drugs; patient selection and response assessment for CT-S; surgical timing and perioperative management; modified techniques for portal vein management; imaging assessment. Available evidence suggests that CT-S may improve oncologic outcomes in carefully selected patients. However, the evidence is derived predominantly from single-arm studies, retrospective cohorts, and real-world investigations. Multicenter prospective studies are therefore required to define criteria for successful conversion, establish the optimal washout interval, clarify postoperative adjuvant strategies, and determine the generalizability of this approach.