Effect of liver function on clinical outcomes in patients with unresectable hepatocellular carcinoma treated with first-line atezolizumab-bevacizumab: an Asia-Pacific multicenter retrospective analysis.

INTRODUCTION AND OBJECTIVES: Atezolizumab+bevacizumab (atezo-bev) is the standard first-line therapy for unresectable hepatocellular carcinoma (uHCC), but pivotal trials were limited to patients with preserved liver function. Therefore, this study aims to evaluate the prognostic effect of Child-Pugh (CP) class and Albumin-Bilirubin (ALBI) grade in real-world patients receiving first-line atezo-bev. MATERIALS AND METHODS: This multinational, multicenter retrospective study included patients with uHCC receiving first-line atezo-bev at five institutions in the Republic of Korea, Singapore, Taiwan, and Hong Kong (July 2016-March 2025). Patients with CP-C were excluded. RESULTS: Among 836 patients (median age, 64 years; 83.5% male), 90.4% had CP-A and 9.6% CP-B; ALBI grades 1, 2, and 3 comprised 41.8%, 55.7%, and 2.4%, respectively. Compared with CP-A, CP-B patients had lower ORR (15.0 % vs. 25.4%, p = 0.040) and shorter median PFS (2.7 vs 6.3 months, p < 0.001) and OS (5.4 vs 18.6 months; p < 0.001). In contrast, ORR was similar across ALBI grades (23.8%, 25.1%, and 20.0% for grades 1-3, respectively; p = 0.816), both median PFS (7.0 vs. 5.6 vs. 2.6 months; p < 0.001) and OS (23.0 vs. 12.7 vs. 4.7 months; p < 0.001) worsened with higher ALBI grade. In multivariate analyses, CP class independently predicted PFS and OS, while ALBI predicted OS. CONCLUSIONS: Liver function is a key prognostic factor in patients with uHCC treated with atezo-bev. These findings highlight the need to assess liver function when selecting systemic therapy and support further studies, including patients with impaired liver function.