Ablation‐Based Salvage Strategy at Disease Progression After Initial Disease Control With Atezolizumab/Bevacizumab in Hepatocellular Carcinoma

Background Patients with unresectable hepatocellular carcinoma (HCC) who initially achieve disease control with atezolizumab plus bevacizumab (Atez/Bev) eventually develop progressive disease (PD). Treatment is usually shifted to subsequent systemic therapy, whereas ablation is rarely considered. We investigated whether ablation at PD could serve as a salvage option in selected patients after initial disease control with Atez/Bev. Methods From a multicenter database involving 16 institutions, we identified 186 patients with unresectable HCC who achieved partial response or stable disease with first‐line Atez/Bev and subsequently developed PD between 2020 and 2025. Postprogression survival (PPS) and overall survival (OS) were compared between ablation and nonablation groups using propensity score matching (PSM). Multivariable Cox regression was performed for both OS and PPS. Inverse probability of treatment weighting (IPTW) and landmark analysis were used as sensitivity analyses. Results After PSM, 20 matched pairs were analyzed. OS tended to be longer in the ablation group than in the nonablation group (not reached vs. 25.7 months and p = 0.090). PPS was significantly longer in the ablation group (37.7 vs. 9.17 months and p = 0.043). In multivariable analyses adjusted for ALBI score and tumor number, ablation showed a trend toward improved OS (HR 0.393 and p = 0.063) and was associated with prolonged PPS (HR 0.335 and p = 0.035), although residual confounding limits causal inference. Sensitivity analyses showed consistent results. Conclusion In selected patients who initially achieved disease control with Atez/Bev, ablation at PD may be a potential salvage approach associated with prolonged PPS. These exploratory and hypothesis‐generating findings warrant prospective validation of ablation‐based salvage strategies.