Surgical resection versus non-surgical treatments for hepatocellular carcinoma with macrovascular invasion

The optimal treatment strategy for hepatocellular carcinoma (HCC) with macrovascular invasion (MaVI) remains unclear. The study aimed to compare the survival outcomes between surgical resection (SR) and non-surgical resection (non-SR) treatments for HCC patients with MaVI. We conducted systematic search for relevant studies from January 1990 to July 2023. Two levels of subgroup analyses were conducted based on tumor thrombosis types and treatment modalities in non-SR group. A cumulative meta-analysis was performed and sensitivity analysis assessed the robustness of the results. Begg's test, Egger's test, and funnel plots were used to identify publication bias. The meta-analysis included 33 studies with 10,551 patients (SR, n = 4,903 vs. non-SR, n = 5,648). The 1-year (RR = 1.51, 95% CI:1.36-1.68, I² = 80.9%, P < 0.001), 3-year (RR = 1.84, 95% CI:1.56-2.16, I² = 67.7%, P < 0.001), and 5-year (RD = 0.06, 95% CI:0.03-0.08, I² = 74.3%, P < 0.001) overall survival (OS) rates were significantly higher in SR group with MaVI. The SR group with type I portal vein tumor thrombosis (PVTT) showed improved 1-year OS (P = 0.001) but this was not observed in type II PVTT (P = 0.144). Surgery improved 3-year (P = 0.001; P < 0.001) and 5-year OS (P = 0.042; P = 0.001) for patients with type I and II PVTT, respectively. The 1-year (P = 0.05), 3-year (P < 0.001) and 5-year (P = 0.027) OS rates for patients with hepatic vein tumor thrombosis (HVTT) were higher in SR group. Surgery is recommended for HCC patients with type I/II PVTT or HVTT, but the treatment strategy for other MaVI types and should be chosen with caution.