Recent advances in conversion therapy for hepatocellular carcinoma with portal vein tumor thrombosis
- 1Department of General Surgery, Changyi People’s Hospital , ,
- 2Department of Hepatobiliary Surgery, Qilu Hospital of Shandong University , ,
Abstract
Portal vein tumor thrombosis (PVTT) is one of the most clinically consequential manifestations of advanced hepatocellular carcinoma (HCC). It reflects aggressive tumor biology, compromises portal venous inflow, and reduces the therapeutic window for locoregional intervention. Historically, macroscopic portal vein invasion generally placed patients within advanced-stage treatment pathways, in which systemic therapy constituted the standard treatment backbone and curative-intent approaches were applicable only to selected patients. This paradigm has now shifted. In recent years, the management of unresectable HCC has been reshaped by immune-based systemic therapy, more active tyrosine kinase inhibitor-based combinations, hepatic arterial infusion chemotherapy (HAIC), selective transarterial therapies, thrombus-directed radiotherapy, and increasingly standardized multidisciplinary conversion strategies. Consequently, a subset of patients with liver-dominant HCC and PVTT can now be downstaged to radical resection or other definitive local treatment, particularly when liver function is preserved and therapy is initiated before irreversible hepatic decompensation develops. This review summarizes recent advances in the diagnosis and classification of PVTT, the biological and technical rationale for conversion therapy, and the evolving evidence for systemic therapy, HAIC, transarterial chemoembolization (TACE), radiotherapy, triple-modality treatment, salvage surgery, and postoperative management. It also highlights key limitations, including the predominance of retrospective East Asian cohorts, heterogeneity in PVTT classification and treatment protocols, uncertainty regarding the optimal timing of surgery, and the absence of validated biomarkers for selecting patients most likely to benefit from aggressive multimodality treatment. Overall, the available evidence supports integrating response-guided multidisciplinary strategies into established evidence-based treatment frameworks for carefully selected patients. Even so, conversion therapy for HCC with PVTT remains an evidence-evolving strategy that should be applied with careful patient selection, disciplined treatment sequencing, and substantial institutional expertise rather than adopted as a universal standard of care.
Related
- The Efficacy and Safety of Combined Locoregional and Systemic Therapy versus Systemic Therapy Alone in Patients with Hepatocellular Carcinoma and Portal Vein Tumor Thrombosis: A Multicenter Real-World Retrospective Cohort Study.
- Sequential surgery after conversion therapy for advanced hepatocellular carcinoma: Evidence, controversies, and perspectives
- Pathological Complete Response and Successful Conversion Hepatectomy in Initially Unresectable Giant Hepatocellular Carcinoma Following Triple Therapy With HAIC, Bevacizumab, and Tislelizumab: A Case Report
- Conversion Surgery After HAIC-Based Combination Therapy with Targeted Therapy and Immune Checkpoint Inhibitors for Initially Unresectable Hepatocellular Carcinoma: A Retrospective Cohort Study
- Resection rates after conversion therapy for initially unresectable hepatocellular carcinoma: a systematic review and meta-analysis
BibTeX
@article{xie2026recent,
title = {{Recent advances in conversion therapy for hepatocellular carcinoma with portal vein tumor thrombosis}},
author = {Panpan Xie and Jianfang Zhu and Peng Xu and Peng Zhang and Fengguo Jian},
journal = {Frontiers in oncology},
year = {2026},
month = sep,
doi = {10.3389/fonc.2026.1925747},
url = {https://europepmc.org/article/PMC/PMC13662787},
note = {CC BY},
}
RIS
TY - JOUR
TI - Recent advances in conversion therapy for hepatocellular carcinoma with portal vein tumor thrombosis
AU - Panpan Xie
AU - Jianfang Zhu
AU - Peng Xu
AU - Peng Zhang
AU - Fengguo Jian
PY - 2026
DA - 2026/09/30
JO - Frontiers in oncology
DO - 10.3389/fonc.2026.1925747
UR - https://europepmc.org/article/PMC/PMC13662787
AB - Portal vein tumor thrombosis (PVTT) is one of the most clinically consequential manifestations of advanced hepatocellular carcinoma (HCC). It reflects aggressive tumor biology, compromises portal venous inflow, and reduces the therapeutic window for locoregional intervention. Historically, macroscopic portal vein invasion generally placed patients within advanced-stage treatment pathways, in which systemic therapy constituted the standard treatment backbone and curative-intent approaches were applicable only to selected patients. This paradigm has now shifted. In recent years, the management of unresectable HCC has been reshaped by immune-based systemic therapy, more active tyrosine kinase inhibitor-based combinations, hepatic arterial infusion chemotherapy (HAIC), selective transarterial therapies, thrombus-directed radiotherapy, and increasingly standardized multidisciplinary conversion strategies. Consequently, a subset of patients with liver-dominant HCC and PVTT can now be downstaged to radical resection or other definitive local treatment, particularly when liver function is preserved and therapy is initiated before irreversible hepatic decompensation develops. This review summarizes recent advances in the diagnosis and classification of PVTT, the biological and technical rationale for conversion therapy, and the evolving evidence for systemic therapy, HAIC, transarterial chemoembolization (TACE), radiotherapy, triple-modality treatment, salvage surgery, and postoperative management. It also highlights key limitations, including the predominance of retrospective East Asian cohorts, heterogeneity in PVTT classification and treatment protocols, uncertainty regarding the optimal timing of surgery, and the absence of validated biomarkers for selecting patients most likely to benefit from aggressive multimodality treatment. Overall, the available evidence supports integrating response-guided multidisciplinary strategies into established evidence-based treatment frameworks for carefully selected patients. Even so, conversion therapy for HCC with PVTT remains an evidence-evolving strategy that should be applied with careful patient selection, disciplined treatment sequencing, and substantial institutional expertise rather than adopted as a universal standard of care.
SN - 2234-943X
ER -