Abstract
BACKGROUND: Portal vein tumour thrombus (PVTT) significantly worsens the prognosis of hepatocellular carcinoma. Although combination therapy involving immune checkpoint inhibitors, anti-angiogenics, and locoregional treatment has shown promising anti-tumour activity, the comparative effectiveness of liver resection versus transarterial chemoembolization within such regimens remains unclear. METHODS: This multicentre, retrospective study enrolled patients with hepatocellular carcinoma and PVTT who received either liver resection or transarterial chemoembolization, each combined with PD-1 inhibitors and lenvatinib (LRPL and TPL, respectively), between 2019 and 2023. Survival outcomes were compared using the Kaplan-Meier method. Propensity score matching was applied to balance baseline characteristics and reduce potential confounding between the two groups. RESULTS: A total of 430 patients were included, and 155 patients remained in each cohort after 1:1 propensity score matching. The LRPL cohort showed significantly longer overall survival than the TPL cohort, with a median(interquartile range) overall survival of 34.0 (30.0-45.9) months versus 22.9 (19.3-31.2) months (hazard ratio 0.71, 95% confidence interval 0.53 to 0.95; P < 0.001). Subgroup analysis revealed that the overall survival benefit of LRPL was primarily observed in patients with PVTT limited to secondary branches (hazard ratio 0.36, 0.21 to 0.64; P < 0.001). In contrast, no significant difference was found when PVTT involved the primary branches or main trunk (hazard ratio 0.91, 0.68 to 1.41; P = 0.240). CONCLUSIONS: The LRPL strategy was associated with superior survival compared with TPL, especially in patients with secondary branch PVTT, indicating its potential as the preferred therapeutic option for this patient population.