The role of stereotactic body radiotherapy in the management of hepatocellular carcinoma with macroscopic vascular invasion: a narrative review

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, with a rising global incidence. Prognosis in HCC remains poor, particularly in patients presenting with macrovascular invasion (MVI), which is associated with high rates of hepatic decompensation, diffuse disease progression, and a median survival of only 2-5 months without treatment. Management of HCC with MVI is complex, requiring multidisciplinary and multimodality approaches. While surgery and transplantation may be considered in select cases, systemic therapy with immunotherapy-based regimens currently represents standard of care. Limitations due to complications with MVI often makes optimal treatment challenging. Advances in modern radiotherapy, particularly stereotactic body radiotherapy (SBRT), have established it as a safe and effective local therapy capable of delivering ablative doses while sparing normal liver tissue. Retrospective series and prospective trials have demonstrated that SBRT provides high local control rates, objective response rates exceeding 50%, and survival benefits when combined with systemic or locoregional therapies alone. SBRT has also shown promise in improving liver function and palliating symptoms in patients with poor hepatic reserve. Emerging evidence suggests synergistic effects when combined with immunotherapy or transarterial therapies, with ongoing studies poised to clarify its role in modern treatment paradigms. Collectively, data support the use of SBRT as a crucial tool in the multidisciplinary management of HCC with MVI, offering durable local control, symptom relief, and the potential to enhance systemic therapy efficacy.