Interventional Management of Patients with Hepatocellular Carcinoma and Portal Vein Tumor Thrombosis: Are There Differences Between East and West?
This review summarizes current evidence on interventional therapies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT), compares the treatment strategies between East and West, and proposes a practical framework for patient selection in the immunotherapy era of HCC.
Although systemic therapy remains the primary treatment for advanced HCC with PVTT, selected interventional therapies may provide additional value in carefully chosen patients with preserved liver function, liver-dominant disease, anatomically targetable PVTT, and adequate or reconstructable portal venous flow. Interventional options include transarterial chemoembolization, hepatic arterial infusion chemotherapy, transarterial radioembolization/selective internal radiation therapy, radiotherapy, portal vein stenting, and iodine-125 seed-based endovascular brachytherapy. Eastern and Western practice patterns differ mainly in the threshold for locoregional intensification, technical platform availability, and interpretation of the available evidence. Eastern and Western approaches increasingly share the principle that systemic therapy is the treatment backbone for advanced HCC with PVTT. The key clinical question is how interventional therapy should be integrated for selected patients rather than whether it should replace systemic therapy. Optimal management should be individualized through multidisciplinary decision-making based on PVTT extent, portal venous flow, liver function, intrahepatic and extrahepatic tumor burden, treatment goals, and institutional expertise. Future studies should standardize reporting of PVTT classification, portal vein patency, collateral circulation, liver reserve, tumor distribution, systemic therapy context, and treatment sequencing.
Although systemic therapy remains the primary treatment for advanced HCC with PVTT, selected interventional therapies may provide additional value in carefully chosen patients with preserved liver function, liver-dominant disease, anatomically targetable PVTT, and adequate or reconstructable portal venous flow. Interventional options include transarterial chemoembolization, hepatic arterial infusion chemotherapy, transarterial radioembolization/selective internal radiation therapy, radiotherapy, portal vein stenting, and iodine-125 seed-based endovascular brachytherapy. Eastern and Western practice patterns differ mainly in the threshold for locoregional intensification, technical platform availability, and interpretation of the available evidence. Eastern and Western approaches increasingly share the principle that systemic therapy is the treatment backbone for advanced HCC with PVTT. The key clinical question is how interventional therapy should be integrated for selected patients rather than whether it should replace systemic therapy. Optimal management should be individualized through multidisciplinary decision-making based on PVTT extent, portal venous flow, liver function, intrahepatic and extrahepatic tumor burden, treatment goals, and institutional expertise. Future studies should standardize reporting of PVTT classification, portal vein patency, collateral circulation, liver reserve, tumor distribution, systemic therapy context, and treatment sequencing.