Surgical resection versus non-surgical treatment for hepatocellular carcinoma with portal vein tumor thrombosis: A comprehensive systematic review and meta-analysis

Background: The role of surgical resection (SR) as a primary treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) remains uncertain. Methods: A comprehensive search of electronic databases from January 2000 to April 2024 identified studies comparing SR with transarterial chemoembolization (TACE), combined TACE and radiation therapy (TACE-RT), or sorafenib. Meta-analyses were conducted for comparison groups with at least three eligible studies. Hazard ratios (HRs) with 95 percent confidence intervals (CIs) for overall survival (OS) were extracted or reconstructed from Kaplan-Meier curves. Results: Twelve retrospective cohort studies involving 4,498 patients were included. SR demonstrated superior long-term OS compared with TACE in Vp1-2 (5-year OS: HR 0.53, 95% CI 0.35-0.79) and Vp3 (5-year OS: HR 0.68, 95% CI 0.61-0.75), with comparable outcomes in Vp4. SR and TACE-RT showed similar 1- and 3-year OS, although SR demonstrated a clear 5-year OS advantage in Vp1-3 PVTT (HR 0.48, 95% CI 0.31-0.74). Compared with sorafenib, SR provided superior OS in Vp1-2 (3-year OS: HR 0.26, 95% CI 0.18-0.38) and comparable OS in Vp3. Sensitivity analyses supported the robustness of these findings, and no substantial publication bias was detected. Conclusion: Based on current evidence, SR is not inferior to non-surgical treatments including TACE, TACE-RT, and sorafenib in patients with HCC and PVTT and provides meaningful long-term survival benefits, particularly in those with segmental PVTT (Vp1-Vp2). Further comparative studies incorporating immunotherapy are needed in future research. Key words: Hepatocellular carcinoma; tumor thrombosis; resection; transarterial chemoembolization; meta-analysis.