Management of Hepatocellular Carcinoma with Advanced Portal Vein Tumor Thrombus: Current Evidence and Future Perspectives—A Narrative Review

Portal vein tumor thrombus (PVTT) is one of the most critical adverse prognostic factors in hepatocellular carcinoma (HCC) and is associated with rapid intrahepatic progression, deterioration of liver function, and extremely poor survival. Although Western guidelines generally recommend systemic therapy for HCC with PVTT, increasing evidence from Asian countries has demonstrated that selected patients may benefit from aggressive multidisciplinary treatment strategies including surgical resection, hepatic arterial infusion chemotherapy (HAIC), transarterial chemoembolization (TACE), radiotherapy, and immune checkpoint inhibitor (ICI)-based systemic therapy. Historically, surgical resection has shown survival benefit mainly in Vp1–Vp3 disease, whereas the role of surgery in Vp4 disease remains controversial because prognosis is strongly influenced by tumor biology and liver functional reserve. Recent advances in ICI- and tyrosine kinase inhibitor (TKI)-based therapies have further expanded the feasibility of conversion surgery for initially unresectable disease. Tumor markers, including AFP and DCP, treatment response, and liver function may provide complementary prognostic information in addition to anatomical PVTT extent when determining prognosis and treatment strategy. In this review, we summarize the historical evolution and current evidence regarding surgical resection, perioperative therapy, systemic therapy, and conversion surgery for HCC with PVTT, particularly focusing on advanced Vp3/Vp4 disease. We also discuss the evolving concept of multidisciplinary treatment integration in the immunotherapy era and propose an evidence-based treatment algorithm for clinical practice.