Background: Hepatocellular carcinoma (HCC) patients associated with portal vein tumor thrombosis (PVTT) have less therapeutic options and carry a worse prognosis. Surgical and local treatments are contemplated only in a select few. Renewed interest has been established in radiotherapy (RTH) as a treatment modality in HCC but a direct comparison to systemic agents is lacking. Methods: A retrospective comparative review of patients with unresectable HCC having PVTT that received sorafenib or RT. Overall survival and toxicity were compared between the two groups and analyses were performed. Results: From 2018 - 2021 60 HCC with PVTT patients were equally divided between the two treatment arms. The two groups were well balanced with 90% being HCV positive, however a significant difference was observed for ECOG PS of 1 vs. 0 in the RTH and sorafenib arms respectively (80% vs. 50%; p=0.015). Likewise a significance in PVTT response was found in the RTH group vs. the systemic one (p=0.012). Median survival did not differ significantly between the sorafenib group (8 months) and the RT group (10 months; P = 0.258) and adverse events were equally encountered. A highly significant relation (p value <0.001) for AFP reduction and being a responder (achieving CR and PR) to either therapy in the tumor or thrombus was observed. The RTH group displayed significance relevant to the size (p = 0.029) and location (p value <0.001) of the thrombus; whilst the sorafenib group HBV negative cases fared better (p = 0.040). Conclusions: RTH for unresectable HCC with PVTT is comparable to sorafenib. It provides a therapeutic option deserving further incorporation into the multidisciplinary care of these cases.