Neoadjuvant radiotherapy for resectable hepatocellular carcinoma with vascular invasion: A systematic review and...

Advances in conformal and image-guided external-beam radiotherapy have expanded its application in hepatocellular carcinoma (HCC); however, the benefit of neoadjuvant radiotherapy before resection for HCC with vascular invasion remains uncertain. A systematic review and meta-analysis were conducted comparing neoadjuvant radiotherapy plus hepatectomy vs. hepatectomy alone in resectable HCC with vascular invasion. Databases were searched through August 1, 2024. Primary outcomes were overall survival (OS) and disease-free survival (DFS). A total of four studies (n=362) were included. In the overall pooled analysis, neoadjuvant radiotherapy was not associated with a statistically significant improvement in 1-year OS [risk ratio (RR) 1.62; 95% confidence interval (CI) 0.71-3.69] or 2-year OS (RR 2.64; 95% CI 0.57-12.27), with considerable heterogeneity (I² 97 and 94%, respectively). Similarly, 1-year DFS was not significantly different between groups (RR 2.68; 95% CI 0.50-14.43; I² 95%). In subgroup analyses by vascular invasion type, patients with portal vein tumor thrombus (PVTT) showed a higher 1-year and 2-year OS compared with surgery alone, and two studies reporting time-to-event outcomes suggested lower recurrence and mortality; however, these findings are based on a small number of studies and should be interpreted with caution. Reported radiotherapy-related toxicities were generally manageable. Overall, current evidence is limited and heterogeneous; neoadjuvant radiotherapy may benefit selected patients with resectable HCC and PVTT, but adequately powered multicenter randomized trials with standardized protocols are needed.