Vascular Invasion Within the Resectability Criteria Is a Prognostic Factor in Patients Treated With Atezolizumab and Bevacizumab

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BACKGROUND AND AIMS: To assess the outcomes of patients with hepatocellular carcinoma (HCC) who were treated with atezolizumab plus bevacizumab (Atezo/Bev), categorised by oncological resectability criteria, which reflect tumour burden and extent of disease. METHODS: A cohort of 467 HCC patients who received Atezo/Bev was enrolled. Patients were classified into two groups based on oncological resectability criteria: BR (borderline resectable) 1 (n = 153) and BR2 (n = 314). RESULTS: The median progression-free survival (PFS) was 9.0 months in the BR1 group and 6.8 months in the BR2 group (p = 0.014). Multivariable analysis identified the following independent prognostic factors for PFS: age ≥ 75 years (hazard ratio [HR], 1.309), albumin-bilirubin (ALBI) grade ≥ 2 (HR, 1.494), neutrophil-to-lymphocyte ratio (NLR) ≥ 3 (HR, 1.289), α-fetoprotein ≥ 100 ng/mL (HR, 1.523) and BR2 classification (HR, 1.360). The median overall survival (OS) was 25.3 months in the BR1 group and 22.3 months in the BR2 group (p = 0.048). Multivariable analysis identified the following independent prognostic factors for OS: age ≥ 75 years (HR, 1.522), ALBI grade ≥ 2 (HR, 2.411), NLR ≥ 3 (HR, 1.635), α-fetoprotein ≥ 100 ng/mL (HR, 1.530) and BR2 classification (HR, 1.421). When oncological resectability factors (tumour number and size, vascular invasion and extrahepatic spread) were incorporated into the multivariable analysis, major vascular invasion emerged as a significant predictor of both PFS (HR, 3.188) and OS (HR, 2.650). CONCLUSIONS: In patients with HCC characterised by limited resectability undergoing Atezo/Bev, vascular invasion, in addition to liver function, is a critical prognostic determinant of tumour progression.