Impacts of Liver Resection with Neoadjuvant Treatment Versus Surgery Alone in Hepatocellular Carcinoma with Portal Vein Tumour Thrombosis: A Systematic Review and Meta-Analysis

Background: Hepatocellular carcinoma (HCC) with portal vein tumour thrombosis (PVTT) has a poor prognosis, and the benefits of neoadjuvant therapy are unclear. This systematic review and meta-analysis aim to evaluate the impact of neoadjuvant treatment (NAT) followed by surgery versus surgery alone on survival outcomes. Methods: A PRISMA-compliant systematic review was conducted by searching the OVID databases Embase, Medline, PubMed, and Scopus for English-language comparative studies of resectable HCC with PVTT, up to 23 January 2025. Two reviewers independently screened, extracted data, and assessed risk of bias (ROBINS-I/ROB2). Hazard ratios (HRs) for overall survival (OS) and recurrence-free survival (RFS) were pooled for meta-analysis. Results: Seven studies (2015–2024, five retrospective cohorts, one non-randomised comparative, one RCT) included 621 patients. The pooled analysis demonstrated that NAT followed by surgery was associated with a significantly improved OS (HR: 0.48, 95% CI: 0.295–0.67, p-value < 0.001, I2 = 0.00) and improved RFS (HR: 0.4, 95% CI: 0.2–0.58, p-value < 0.001, I2 = 0.00). Conclusions: For patients with HCC and an associated PVTT, neoadjuvant treatment before surgery significantly improves both overall and recurrence-free survival. These findings support a multimodal approach. Current evidence is largely non-randomised and HBV-endemic, warranting prospective validation in aetiologically diverse cohorts, including Western ones.