SBRT for Extensive Macrovascular Invasion in HCC- J Hepatol Feb.26

Macrovascular invasion (MVI) in hepatocellular carcinoma (HCC), particularly involving the hepatic veins, inferior vena cava, or right atrium, is associated with extremely poor prognosis and limited treatment options. Systemic therapy is the standard of care, but many patients with extensive MVI experience rapid deterioration in liver function, making systemic treatment poorly tolerated or infeasible. Evidence to guide management in this subgroup is sparse, as such patients are often excluded from clinical trials.

This report highlights the role of stereotactic body radiotherapy (SBRT) as an effective local therapy for extensive MVI. In the described case, SBRT targeting the vascular tumor thrombus resulted in marked radiologic response, substantial reduction in tumour burden, and—critically—improvement in liver function, allowing safe reintroduction of systemic therapy. Tumor markers fell dramatically, and durable local control of the macrovascular disease was achieved.

The case is supported by growing evidence from retrospective series and prospective trials showing that SBRT achieves high local control rates in HCC with MVI, with acceptable toxicity. Importantly, radiation to macrovascular tumour thrombus can restore or preserve hepatic blood flow, stabilise liver function, and create an opportunity for sequential systemic therapy. Randomised data suggest that combining radiotherapy with other treatments improves outcomes compared with systemic therapy alone.

In summary, SBRT is a valuable treatment option for HCC with extensive MVI, even in advanced cases. By controlling vascular invasion and improving liver function, SBRT may expand therapeutic possibilities and improve outcomes in a population with otherwise very limited options.