Baseline ALBI Grade as an Independent Prognostic Factor of Survival in High-Risk Real-World HCC Under Atezolizumab-Bevacizumab.

BACKGROUND/AIM: Atezolizumab plus bevacizumab is the current first-line standard for unresectable hepatocellular carcinoma (HCC). However, real-world populations often differ substantially from clinical trials particularly in terms of hepatic reserve and tumor burden. We aimed to evaluate survival outcomes and hepatic functional changes in a real-world cohort, specifically focusing on the prognostic role of baseline ALBI grade and portal vein tumor thrombosis (PVTT). METHODS: This multicenter retrospective cohort study analyzed 43 patients with BCLC-B/C unresectable HCC treated between January 2022 and June 2025. Tumor response was assessed according to mRECIST. Overall survival (OS) and progression-free survival (PFS) were estimated using the Kaplan-Meier method. Cox regression analyses were performed to identify independent prognostic factors. RESULTS: The cohort was characterized by advanced disease (72.1% BCLC-C stage, 74.5% ALBI grade ≥2, and 41.9% PVTT). Median OS and PFS were 9.5 months (95% CI, 6.5-12.4) and 6 months (95% CI, 3.8-8.2), respectively. Patients with ALBI grade 1 had significantly longer OS compared to those with ALBI ≥2 (21 vs 8 months; p=0.018). In multivariable Cox regression analysis, higher baseline ALBI grade was independently associated with shorter OS (HR 3.1, 95% CI 1.1-8.3; p=0.027) and PFS (HR 2.8, 95% CI 1.2-6.9; p=0.021). Hepatic decompensation occurred in 41.9% of patients and was associated with deterioration in liver function scores. CONCLUSION: In this high-risk real-world cohort of patients with HCC treated with atezolizumab plus bevacizumab, baseline ALBI grade was independently associated with poorer survival outcomes, suggesting that hepatic functional reserve may be important for prognostic stratification. Larger prospective studies are needed to clarify the relative prognostic contributions of ALBI grade and tumor-related factors such as PVTT.