Outcomes of Hepatocellular Carcinoma involving the Portal Vein Main Trunk and/or the Inferior Vena Cava: Experience From a Multidisciplinary Liver Cancer Clinic

BACKGROUND: Vascular invasion by hepatocellular carcinoma (HCC), particularly involving the main portal vein or inferior vena cava (IVC), is associated with poor prognosis. However, contemporary real-world outcomes and the clinical benefit of liver-directed therapies (LDT) in this setting are poorly defined. We evaluated outcomes of patients with vascular invasion managed in a multidisciplinary liver cancer clinic. METHODS: We retrospectively analyzed outcomes for patients with HCC who presented to the Johns Hopkins Liver Multidisciplinary Clinic between 2020 and 2024, with radiographic evidence of the tumor thrombus in the main portal vein and/or IVC. Overall (OS) and progression-free survival and gastrointestinal variceal bleeding incidence were evaluated. Associations between clinical variables and outcomes were analyzed using the Cox proportional hazards regression. RESULTS: Fifty-four patients met our study criteria. Forty-eight patients (89%) had portal vein main trunk invasion, and 13 (24%) had IVC tumor thrombus. Treatment included systemic therapy alone in 30 patients (56%), systemic therapy and LDT in 15 patients (28%), best supportive care in six patients (11%), and LDT alone in three patients (6%). Median OS was 5.7 months (95% CI: 2.6-12 months). Median survival was shorter among patients with IVC involvement (4.1 months, 95% CI: 0.82-5.7 months) than those without (7.6 months, 95% CI: 2.3-17 months), which was independently associated with worse prognosis in multivariable analysis (HR: 4.0, 95% CI: 1.5-11, p = 0.0051). Other significant findings of multivariable analysis include performance status (HR: 7.2, 95% CI: 2.7-19, p < 0.0001) and viral hepatitis (HR: 0.46, 95% CI: 0.23-0.79, p = 0.027). Four patients (7%) experienced bleeding esophageal varices requiring intervention. CONCLUSIONS: HCC with tumor thrombus involving the main portal vein and/or IVC is associated with poor survival in real-world clinical practice. Prospective studies are needed to define the optimal management of this high-risk population.