Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death worldwide, accounting for 7.8% of cancer deaths in 2024, following lung (18.7%) and colorectal (9.3%) cancers (Bray et al., 2024). HCC is frequently diagnosed at an advanced stage, with portal vein tumor thrombosis (PVTT) representing a major prognostic factor linked to poor survival. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, PVTT corresponds to advanced-stage disease (BCLC C), for which sorafenib has historically been the standard of care [1]

Over the past decades, the treatment landscape for PVTT has evolved considerably. In the 1980s and 1990s, systemic therapies such as chemotherapy and hormonal treatments were the mainstay but showed limited effectiveness [2]. The introduction of locoregional therapies, particularly transarterial chemoembolization (TACE) and transarterial radioembolization (TARE), in the 1990s and early 2000s, improved disease control and survival in selected patients [3,4]. Subsequently, external beam radiotherapy (EBRT) and stereotactic body radiotherapy (SBRT) were adopted in clinical practice, allowing for more precise targeting of PVTT and enabling potential downstaging in some cases [5,6]. During this same period, liver resection gained traction, particularly in Asian countries, for well-selected patients with limited PVTT [7,8]. In recent years, liver transplantation has been reconsidered in select patients following successful neoadjuvant downstaging, challenging its long-standing contraindication in PVTT cases [9]

This article presents a narrative review of the evolving management of PVTT in HCC, with a particular focus on the role of locoregional therapies. A structured literature search was conducted using PubMed, applying specific keywords tailored to each therapy to refine the scope of results. In addition, OpenEvidence was used to address targeted clinical questions, incorporating relevant clinical trials and meta-analyses where available. The review is presented largely in chronological order to reflect the historical development and clinical integration of these treatment strategies.