This retrospective international multicenter study evaluated clinical predictors of response to first-line atezolizumab/bevacizumab (A/B) in 246 Child-Pugh B patients with unresectable HCC (out of 1,499 total), treated across 12 centers from 2020–2024, with a sorafenib-treated Child-Pugh B cohort as control.
Median OS was 8.1 months (Child-Pugh B) vs. 16.8 months (Child-Pugh A; p<0.001); A/B outperformed sorafenib in Child-Pugh B (p=0.002). A composite score of ALBI grade 1/2 + no extrahepatic metastasis identified three prognostic subgroups with median OS of 10.3, 7.9, and 4.2 months (p<0.0001). Child-Pugh class improved to A in 31% of B patients, linked to treatment of underlying liver disease.
Retrospective design limits causal inference. The sorafenib control group was not matched or randomized, introducing potential selection bias. Child-Pugh B9 patients were underrepresented (6.5%), limiting conclusions for the most impaired subgroup.
In Child-Pugh B patients with HCC, consider first-line atezolizumab/bevacizumab preferentially for those with ALBI grade 1/2 and no extrahepatic metastases — this subgroup shows the most meaningful benefit. Actively treating the underlying liver disease (e.g., viral hepatitis, alcohol) alongside systemic therapy may improve hepatic function and outcomes.
