Patients with Child-Pugh B hepatocellular carcinoma face significantly poorer survival rates than those with compensated liver disease. However, a large multicenter analysis indicates a clinically meaningful subset may still benefit from first-line atezolizumab and bevacizumab combination therapy.
Across 1,499 patients treated between 2020 and 2024, median overall survival for the Child-Pugh B group was 8.1 months compared to 16.8 months for Child-Pugh A patients. Despite this gap, the Child-Pugh B cohort receiving the immunotherapy combination experienced longer overall survival than those treated with sorafenib. This reinforces potential benefits even amid advanced liver impairment.
Pivotal trials establishing this regimen as standard care previously excluded Child-Pugh B patients. Real-world evidence is therefore critical for this heterogeneous population. Researchers found that the ALBEX score, which integrates ALBI grade and metastatic status, effectively stratifies patients into distinct prognostic categories. Median survival ranged from 10.3 months in favorable groups to 4.2 months in the poorest outcomes.
Patients with ALBI grade 1 or 2 and no extrahepatic metastasis appeared most likely to derive benefit. Furthermore, liver function improved in approximately 31% of Child-Pugh B patients, linking tumor response directly to reduced mortality risk.
These findings suggest Child-Pugh B status should not uniformly exclude patients from combination immunotherapy. Integrating ALBI grade, metastatic burden, and dynamic liver function changes offers a refined framework for identifying candidates who can meaningfully benefit from systemic therapy alongside liver health optimization.