What are the treatment considerations for a patient classified as Child-Pugh (Child-Pugh scoring system) B?

Treatment Approach for Child-Pugh B Cirrhosis

For patients with Child-Pugh B cirrhosis and advanced hepatocellular carcinoma (HCC), a cautious approach to systemic therapy is recommended using PD-1/PD-L1 inhibitors, sorafenib, or lenvatinib, but only in patients with good performance status after careful multidisciplinary evaluation of bleeding risk, portal hypertension, tumor burden, and vascular invasion. 1

Key Treatment Considerations

Systemic Therapy Options for HCC

The 2024 ASCO guidelines specifically recommend the following agents for Child-Pugh B patients with good performance status: 1

• PD-1 or PD-L1 inhibitors (nivolumab demonstrated median OS of 7.6 months in Child-Pugh B patients with safety profile comparable to Child-Pugh A) 1
• Sorafenib (though OS may be similar to best supportive care at approximately 5 months) 1
• Lenvatinib (with caution, as treatment-related adverse events are higher in Child-Pugh B) 1

Critical Exclusions and Contraindications

Bevacizumab plus atezolizumab is NOT currently recommended for Child-Pugh B patients due to particular concerns about bleeding risk in this population. 1

Protease inhibitors for hepatitis C are contraindicated in Child-Pugh B and absolutely contraindicated in Child-Pugh C decompensated cirrhosis due to higher drug exposures. 1

Pre-Treatment Risk Assessment Algorithm

Before initiating any systemic therapy in Child-Pugh B patients, evaluate: 1

• Liver function parameters (bilirubin, albumin, INR, ascites, encephalopathy)
• Bleeding risk (platelet count, varices, coagulopathy)
• Portal hypertension presence (imaging, clinical signs)
• Tumor characteristics (extrahepatic spread, tumor burden, major vascular invasion)
• Performance status (ECOG 0-1 required)

Evidence Quality and Limitations

The evidence supporting treatment in Child-Pugh B is of very low quality with weak strength of recommendation. 1 This reflects:

• Most randomized trials excluded Child-Pugh B patients and only enrolled Child-Pugh A 1
• The CheckMate 040 trial prospectively treated only 49 Child-Pugh B7-B8 patients with nivolumab, achieving 12% objective response 1
• Higher treatment discontinuation rates occur in Child-Pugh B compared to Child-Pugh A 1
• Retrospective data show similar or higher adverse event rates in Child-Pugh B patients 1

Shared Decision-Making Imperative

Given modest expectations for clinical benefit, shared decision-making with patients is essential, emphasizing that potential benefits must be weighed against toxicity risks. 1

The discussion should include:

• Expected median survival of 5-7.6 months with treatment 1
• Higher adverse event rates compared to Child-Pugh A 1
• Possibility that outcomes may not differ significantly from best supportive care 1

Multidisciplinary Team Requirement

Treatment decisions should be made by a multidisciplinary team including hepatologists, surgeons, interventional radiologists, pathologists, and oncologists. 1

Common Pitfalls to Avoid

• Do not assume Child-Pugh B is homogeneous: Child-Pugh B7 patients may tolerate therapy better than B8-B9 1
• Do not use bevacizumab-containing regimens: Bleeding risk is prohibitively high 1
• Do not proceed without assessing performance status: Only good PS patients should be considered 1
• Do not neglect liver transplant evaluation: For selected patients meeting criteria, transplantation remains the best long-term option 2, 3

Monitoring Requirements

For patients receiving systemic therapy: 1

• Hepatic function at weeks 4,8, and 12 of therapy
• Renal function regularly if using sorafenib (contains sofosbuvir-like considerations)
• Clinical side effects at each visit
• Treatment-related adverse events more frequently than in Child-Pugh A patients

Child-Pugh C Distinction

Systemic therapy options are NOT recommended for Child-Pugh C patients, who should receive only supportive palliative care or be evaluated for liver transplantation if they meet strict criteria. 1, 2, 3