Abstract
Portal vein tumor thrombus (PVTT) develops in up to half of patients with hepatocellular carcinoma (HCC) and historically signifies advanced-stage disease with limited treatment options and poor prognosis. Systemic therapy has been the standard treatment for HCC with PVTT, but this review highlights the potential of image-guided locoregional therapies including transarterial chemoembolization (TACE), transarterial embolization (TAE) radioembolization (TARE), hepatic arterial infusion chemotherapy (HAIC), and ablative or radiotherapeutic approaches to improve outcomes in this challenging context. We will summarize current evidence and clinical experience demonstrating that these modalities can achieve meaningful tumor control and extend survival, especially when tailored to tumor burden and PVTT extent or combined with systemic treatments. These findings underscore that aggressive locoregional treatment can be a valuable component of multidisciplinary management for advanced HCC, offering select patients an improved prognosis despite PVTT.