What Child-Pugh score is required to initiate treatment with atezolizumab (atezolizumab) and bevacizumab (bevacizumab) for hepatocellular carcinoma (HCC)?

From the Guidelines

For treatment with atezolizumab and bevacizumab in hepatocellular carcinoma (HCC), patients should have Child-Pugh Class A liver function. This combination therapy is specifically indicated for patients with unresectable or metastatic HCC who have not received prior systemic therapy, but only when liver function is well-preserved (Child-Pugh A) 1. Patients with Child-Pugh B or C (indicating moderate to severe liver dysfunction) are generally not candidates for this regimen due to increased risks of adverse events, particularly bleeding complications from bevacizumab. The restriction to Child-Pugh A patients is based on clinical trial data, as the IMbrave150 trial that established this combination as a first-line treatment for HCC primarily included patients with well-preserved liver function 1. This limitation exists because patients with more advanced cirrhosis typically have portal hypertension, coagulopathy, and other complications that increase the risk of serious side effects from these medications, particularly the anti-angiogenic effects of bevacizumab. Some key points to consider when initiating atezolizumab and bevacizumab therapy include:

• Patients should undergo endoscopic evaluation and treatment for esophageal varices before treatment to minimize the risk of gastrointestinal bleeding 1.
• The combination of atezolizumab and bevacizumab has been shown to improve overall survival and progression-free survival compared to sorafenib in patients with Child-Pugh A liver function 1.
• The recommended doses are atezolizumab 1200 mg IV every 3 weeks and bevacizumab 15 mg/kg IV every 3 weeks 1. It is essential to carefully evaluate each patient's liver function and overall health before initiating treatment with atezolizumab and bevacizumab to ensure the best possible outcomes and minimize the risk of adverse events.

From the Research

Child-Pugh Score for Atezolizumab and Bevacizumab Treatment in HCC

• The Child-Pugh score is a crucial factor in determining the suitability of patients with hepatocellular carcinoma (HCC) for treatment with atezolizumab and bevacizumab 2, 3.
• According to the studies, patients with Child-Pugh A liver function are the primary candidates for this treatment, as they have shown better overall survival (OS) rates compared to those with Child-Pugh B or C liver function 2, 3.
• A Child-Pugh score of 7 is identified as a significant factor associated with OS in patients with HCC receiving atezolizumab plus bevacizumab 3.
• Patients with a Child-Pugh score of 7 and an ALBI grade of 1 have shown improved OS rates compared to those with a higher ALBI grade 2.
• The treatment remains a viable option for patients with Child-Pugh B7, although the benefit is significantly less than those with Child-Pugh A 2.
• There is no clear indication of the minimum Child-Pugh score required for treatment with atezolizumab and bevacizumab, but the studies suggest that patients with Child-Pugh A or B7 may be considered for this treatment 2, 3.

Key Findings

• The IMbrave150 trial evaluated atezolizumab plus bevacizumab in patients with Child-Pugh A liver function, showing improved OS and progression-free survival (PFS) rates compared to sorafenib 4, 5.
• A post-hoc analysis of the IMbrave150 study found that ALBI grade is prognostic for outcomes with both atezolizumab plus bevacizumab and sorafenib treatment in patients with HCC 5.
• The safety profiles of atezolizumab and bevacizumab are consistent with previous analyses, regardless of ALBI grade 5.

Treatment Considerations

• Determining the hepatic reserve of patients with unresectable HCC might be useful for identifying patients suitable for systemic treatment with atezolizumab plus bevacizumab 3.
• Lenvatinib administration after atezolizumab plus bevacizumab therapy can be effective, although special attention should be paid to the deterioration of liver function 6.