Risk-based selection of treatment strategies in hepatocellular carcinoma with macrovascular invasion

Background and purpose: The management of hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) remains challenging because of its heterogeneous clinical behavior. Various treatment strategies have been introduced, including transarterial chemoembolization (TACE), tyrosine kinase inhibitors (TKIs) combined with radiotherapy (RT), and atezolizumab/bevacizumab (AB) with or without RT. This study evaluated the efficacy and safety of these approaches by using a previously proposed MVI risk stratification model. Materials and methods: We retrospectively analyzed 526 treatment-naïve patients with HCC and MVI. Patients were categorized into very low/low-risk (n = 259) and intermediate/high-risk (n = 267) groups based on the MVI sub-classification. They were treated with TACE + RT (n = 417), TKI + RT (n = 67), AB alone (n = 25), or AB + RT (n = 17). Survival outcomes, including intrahepatic progression-free survival (IPFS), extrahepatic PFS (EPFS), PFS, and overall survival (OS), were assessed using Kaplan–Meier and multivariate Cox regression analyses. Results: With a median follow-up of 11.6 months, the median IPFS, EPFS, PFS, and OS were 6.3, 7.4, 4.2, and 12.4 months, respectively. The MVI risk group subclassification was significantly correlated with all survival outcomes (p < 0.05). In the very low/low-risk groups, TACE + RT showed superior outcomes compared with TKI + RT. In the intermediate/high-risk group, AB + RT revealed improved survival compared with TACE + RT or AB alone. Liver function deterioration was most frequent in the TKI + RT group. Conclusion: The proposed MVI risk stratification effectively differentiated prognosis and may guide optimal treatment selection for HCC with MVI. Prospective validation is required to confirm the clinical utility.