Portal Hypertension Management in Hepatocellular Carcinoma

Portal hypertension (PH) represents a pivotal challenge in the clinical management of hepatocellular carcinoma (HCC), as both conditions commonly coexist on a background of cirrhosis. Elevated intrahepatic vascular resistance and collateral vessel formation drive PH, predisposing patients to ascites, variceal bleeding and hepatic encephalopathy. In HCC, tumour-related factors such as portal vein tumour thrombosis exacerbate portal pressure, complicating locoregional and systemic therapies. Strategies for PH management in HCC encompass non-invasive risk stratification, endoscopic and pharmacological prophylaxis against variceal haemorrhage, interventional approaches such as transjugular intrahepatic portosystemic shunt placement, and quantitative imaging biomarkers. Effective recognition of at-risk patients allows tailored prophylaxis, optimisation of anti-tumour treatments and improved survival outcomes. Advances in imaging have enabled volumetric assessment of PH markers, while evolving criteria for non-invasive stratification guide decision-making. Interdisciplinary management that balances haemodynamic control and oncological efficacy remains the cornerstone of care.

Research from Nature Portfolio

Quantitative analysis of ascites volume on contrast-enhanced CT has emerged as a strong prognostic indicator in HCC patients undergoing transarterial chemoembolization (TACE). A 2024 study demonstrated that not only the presence but also the absolute volume of ascites independently predicts overall survival, with larger volumes correlating with significantly shorter median survival. Automated segmentation algorithms promise rapid, reproducible ascites quantification, facilitating risk stratification and informing procedural candidacy. This work underscores the value of quantitative imaging biomarkers in guiding TACE candidacy and personalising management of portal hypertension in the HCC setting.

Portal Hypertension Management in Hepatocellular Carcinoma publication trend

The graph below shows the total number of articles in portal hypertension management in hepatocellular carcinoma across all publications each year (not limited to Nature Index journals).

Technical terms

Portal hypertension: Elevated pressure within the portal venous system, often due to cirrhosis, leading to collateral vessel formation and complications such as varices and ascites.

Hepatocellular carcinoma (HCC): A primary malignancy of the liver typically arising against a background of chronic liver disease and cirrhosis.

Ascites: Pathological accumulation of fluid within the peritoneal cavity, reflecting severe portal hypertension and impaired hepatic function.

Varices: Dilated collateral veins, most commonly in the oesophagus or stomach, at high risk of life-threatening bleeding in portal hypertension.

Portal vein tumour thrombosis (PVTT): Invasion of the portal vein by HCC, exacerbating portal pressure and worsening prognosis.

Transarterial chemoembolization (TACE): A locoregional treatment for HCC that delivers chemotherapeutic agents directly to tumour arteries, often combined with embolic materials to induce ischaemia.

Baveno VII criteria: Non-invasive thresholds of liver stiffness and platelet count used to stratify the risk of variceal bleeding and portal hypertension complications.

References

1. Clinical risk factors for portal hypertension-related complications in systemic therapy for hepatocellular carcinoma. Journal of Gastroenterology (2024).
2. Baveno VII Criteria Is an Accurate Risk Stratification Tool to Predict High-Risk Varices Requiring Intervention and Hepatic Events in Patients with Advanced Hepatocellular Carcinoma. Cancers (2023).
3. Amount of ascites impacts survival in patients with hepatocellular carcinoma undergoing transarterial chemoembolization advocating for volumetric assessment. Scientific Reports (2024).
4. Management of varices but not anticoagulation is associated with improved outcome in patients with HCC and macrovascular tumour invasion. Cancer Imaging (2024).
5. Portal hypertension and hepatocellular carcinoma: Des liaisons dangereuses…. Liver International (2021).
6. Variceal bleeding is aggravated by portal venous invasion of hepatocellular carcinoma: a matched nested case-control study. BMC Cancer (2021).
7. The Role of Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Treating Portal Hypertension in Patients with Hepatocellular Carcinoma. Medicina (2023).