Radiotherapy has long been investigated as a therapeutic modality in the management of hepatocellular carcinoma (HCC). Recently, updated clinical frameworks in the Barcelona Clinic Liver Cancer guidelines have allowed greater flexibility in integrating radiotherapy across disease stages. This review synthesizes contemporary prospective studies and systematic reviews/meta-analyses published over the past five years to clarify the current and emerging clinical roles of radiotherapy in real-world HCC management. Recent evidence highlights expanding applications of radiotherapy, including curative-intent stereotactic body radiotherapy in early-stage disease, consolidation after incomplete transarterial chemoembolization, perioperative strategies, and treatment of macroscopic vascular invasion. Radiotherapy is increasingly integrated with tyrosine kinase inhibitors and immune checkpoint inhibitors in advanced, oligometastatic, and oligoprogressive settings. In addition, particle therapies further broaden therapeutic options for liver-confined or anatomically challenging tumors. Collectively, contemporary data indicate that radiotherapy has evolved from a predominantly supportive modality to a versatile and increasingly evidence-based component of multidisciplinary treatment strategies for HCC.

Recently, the survival benefit of immuno-oncologic (IO) agents for advanced hepatocellular carcinoma (HCC) has been proven in several randomized controlled trials. Especially, atezolizumab with bevacizumab (Ate+Beva), as a first-line therapy for advanced HCC, has shown outstanding efficacy in the IMBrave150 study. Fortunately in south Korea, the cost of Ate+Beva therapy can be covered by national medical insurance, therefore HCC patients can receive Ate+Beva therapy without trouble. However, almost all HCC patients have no choice but to stop the treatment after two years completion of Ate+Beva therapy because our national medical insurance only cover IO therapy for two years. Therefore clinicians have been restarting the systemic treatment after confirming the disease progression of HCC patients on resting period of systemic therapy. Here, we report a case that showed a partial response of lymph node metastasis by 3rd line regorafenib therapy for progression of LN metastasis after achieving nearly complete response by two-year completion of 1st line Ate+Beva therapy in advanced HCC patient.