Risk of Variceal Bleeding in Patients Receiving Atezolizumab-Bevacizumab Treatment for Hepatocellular Carcinoma

Background and AimsReal-world data on the variceal bleeding (VB) risk in patients receiving atezolizumab-bevacizumab (Atezo-Bev) treatment remain limited. This study aimed to assess the risk of VB and identify risk factors in patients with advanced hepatocellular carcinoma (HCC) receiving Atezo-Bev treatment.MethodsThis retrospective study included 640 patients with HCC who underwent endoscopy before Atezo-Bev treatment at two hospitals in Korea. The primary outcome was the occurrence of VB, with non-VB events considered as competing events.ResultsOf the 640 patients, the mean age was 61.3 years, and 528 (82.5%) patients were male. The main aetiology of HCC was chronic hepatitis B virus (69.5%), and 563 (88.0%) had BCLC stage C. Portal vein invasion (PVI) was present in 313 (48.9%). During a median follow-up of 5.6 months, 45 (7.0%) patients developed VB. The cumulative incidence of VB was 6.3% at 6 months and 7.4% at 12 months. No patient died from VB. Multivariable analysis revealed that the main PVI (subdistribution hazard ratio [SHR]: 3.49, 95% confidence interval [CI]: 1.63-7.44), low platelet count (SHR: 0.994, 95% CI: 0.99-1.00), a history of gastrointestinal (GI) bleeding (SHR: 3.70, 95% CI: 1.49-9.16) and varices needing treatment (VNT; SHR: 2.67, 95% CI: 1.26-5.64) increased the risk of VB.ConclusionA low platelet count, main PVI, history of GI bleeding and VNT were significant risk factors for VB in patients receiving Atezo-Bev treatment for HCC. Identifying these factors can guide clinicians in assessing and managing VB risk in clinical settings.