Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 7, 2016; 22(1): 407-416
Published online Jan 7, 2016. doi: 10.3748/wjg.v22.i1.407
Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review
Kichang Han, Jin Hyoung Kim, Gi-Young Ko, Dong Il Gwon, Kyu-Bo Sung
Kichang Han, Jin Hyoung Kim, Gi-Young Ko, Dong Il Gwon, Kyu-Bo Sung, Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul 388-1, South Korea
Author contributions: Kim JH designed the study; Ko GY outlined the draft and supervised the project; Gwon DI and Sung KB searched the reference materials; and Han K wrote the manuscript.
Conflict-of-interest statement: The authors do not have any conflicts to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Jin Hyoung Kim, MD, Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap-2dong, Songpa-gu, Seoul 388-1, South Korea.
Telephone: +82-2-30104384 Fax: +82-2-4760090
Received: June 26, 2015
Peer-review started: June 27, 2015
First decision: September 11, 2015
Revised: October 15, 2015
Accepted: November 24, 2015
Article in press: November 24, 2015
Published online: January 7, 2016

The natural history of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal (approximately 2-4 mo), and PVTT is reportedly found in 10%-40% of HCC patients at diagnosis. According to the Barcelona Clinic Liver Cancer (BCLC) Staging System (which is the most widely adopted HCC management guideline), sorafenib is the standard of care for advanced HCC (i.e., BCLC stage C) and the presence of PVTT is included in this category. However, sorafenib treatment only marginally prolongs patient survival and, notably, its therapeutic efficacy is reduced in patients with PVTT. In this context, there have been diverse efforts to develop alternatives to current standard systemic chemotherapies or combination treatment options. To date, many studies on transarterial chemoembolization, 3-dimensional conformal radiotherapy, hepatic arterial chemotherapy, and transarterial radioembolization report better overall survival than sorafenib therapy alone, but their outcomes need to be verified in future prospective, randomized controlled studies in order to be incorporated into current treatment guidelines. Additionally, combination strategies have been applied to treat HCC patients with PVTT, with the hope that the possible synergistic actions among different treatment modalities would provide promising results. This narrative review describes the current status of the management options for HCC with PVTT, with a focus on overall survival.

Keywords: Hepatocellular carcinoma, Portal vein tumor thrombosis, Sorafenib, Transarterial chemoembolization, Transarterial radioembolization, Hepatic arterial chemotherapy, Radiotherapy

Core tip: Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is associated with a grave prognosis if left untreated. Sorafenib is the only treatment modality recommended for treating HCC patients with PVTT according to most international HCC treatment guidelines. However, the survival benefits observed following systemic sorafenib treatment are only marginal. Under these circumstances, the need for better treatment options remains unfulfilled. In this comprehensive review, various treatment options are presented-including transarterial chemoembolization, transarterial radioembolization, hepatic arterial infusion, chemotherapy, and radiotherapy-and their outcomes, along with combination strategies.