# Impacts of Liver Resection with Neoadjuvant Treatment Versus Surgery Alone in Hepatocellular Carcinoma with Portal Vein Tumour Thrombosis: A Systematic Review and Meta-Analysis

## TL;DR

This study finds that combining surgery with neoadjuvant treatment improves survival for liver cancer patients with portal vein tumor thrombosis.

## Contribution

The study provides the first meta-analysis showing that neoadjuvant treatment before surgery improves survival in HCC with PVTT.

## Key findings

- Neoadjuvant treatment before surgery significantly improves overall survival in HCC with PVTT.
- Combined treatment also improves recurrence-free survival compared to surgery alone.
- Current evidence is non-randomized and mostly from HBV-endemic regions, requiring further validation.

## Abstract

Hepatocellular carcinoma (HCC) with portal vein tumour thrombosis (PVTT) is a well-known complication of HCC and is associated with a dismal prognosis, with minimal treatment options. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, HCC with PVTT represents an advanced stage, where systemic therapy is typically the primary treatment. And the role of liver resection after neoadjuvant treatment in this challenging patient group remains unclear. This systematic review and meta-analysis evaluated outcomes of liver resection following neoadjuvant therapy compared with surgery alone in patients with hepatocellular carcinoma (HCC) associated with portal vein tumour thrombosis (PVTT). Pooled data showed that neoadjuvant therapy before resection was associated with improved overall and recurrence-free survival compared with surgery alone. These findings support a combined modality approach in selected patients with HCC and PVTT and highlight the need for future multicentre randomised controlled trials to establish the optimal treatment strategy for this challenging patient group.

Background: Hepatocellular carcinoma (HCC) with portal vein tumour thrombosis (PVTT) has a poor prognosis, and the benefits of neoadjuvant therapy are unclear. This systematic review and meta-analysis aim to evaluate the impact of neoadjuvant treatment (NAT) followed by surgery versus surgery alone on survival outcomes. Methods: A PRISMA-compliant systematic review was conducted by searching the OVID databases Embase, Medline, PubMed, and Scopus for English-language comparative studies of resectable HCC with PVTT, up to 23 January 2025. Two reviewers independently screened, extracted data, and assessed risk of bias (ROBINS-I/ROB2). Hazard ratios (HRs) for overall survival (OS) and recurrence-free survival (RFS) were pooled for meta-analysis. Results: Seven studies (2015–2024, five retrospective cohorts, one non-randomised comparative, one RCT) included 621 patients. The pooled analysis demonstrated that NAT followed by surgery was associated with a significantly improved OS (HR: 0.48, 95% CI: 0.295–0.67, p-value < 0.001, I2 = 0.00) and improved RFS (HR: 0.4, 95% CI: 0.2–0.58, p-value < 0.001, I2 = 0.00). Conclusions: For patients with HCC and an associated PVTT, neoadjuvant treatment before surgery significantly improves both overall and recurrence-free survival. These findings support a multimodal approach. Current evidence is largely non-randomised and HBV-endemic, warranting prospective validation in aetiologically diverse cohorts, including Western ones.