Imaging Features of Patients with Hepatocellular Carcinoma and Portal Vein Tumor Thrombosis Surviving Beyond 1 Year After Combined Therapy

<b>Background/Objectives:</b> Portal vein tumor thrombus (PVTT) is a severe complication of hepatocellular carcinoma (HCC) and is associated with poor outcomes. This study aimed to describe the imaging and clinical characteristics observed among HCC patients with PVTT who survived longer than one year following combined systemic therapy and radiotherapy. <b>Methods:</b> This retrospective, single-center study included 26 consecutive HCC patients with PVTT who survived more than one year after combined treatment. Baseline characteristics included PVTT extent classified according to the Liver Cancer Study Group of Japan-VP1 (segmental portal vein invasion), VP2 (second-order portal vein invasion), VP3 (first-order portal vein invasion), and VP4 (main portal trunk or contralateral PV invasion) and liver function assessed by Child-Pugh class and ALBI grade. Contrast-enhanced CT or MRI was evaluated at baseline and 6 months after treatment using RECIST 1.1 criteria. <b>Results:</b> The cohort was predominantly male (69%), and most patients had extensive PVTT (VP3-VP4, <i>n</i> = 19). Preserved liver function was common at baseline (Child-Pugh class A, <i>n</i> = 24; ALBI grade I, <i>n</i> = 14). Tumor response was observed in 23 patients (88%) during follow-up. Frequently observed post-treatment imaging findings included portal vein recanalization (<i>n</i> = 12), collateral circulation (present in 7 patients at baseline and 6 at follow-up), and compensatory liver hypertrophy (<i>n</i> = 6). <b>Conclusions:</b> Among HCC patients with PVTT who survived longer than one year after combined therapy, portal vein recanalization, collateral circulation, and compensatory liver hypertrophy were commonly observed imaging features. Given the retrospective design and survivor-selection nature of the study, these findings should be interpreted as descriptive observations rather than evidence of treatment efficacy or prognostic determinants.