PATIENTS with Child-Pugh B hepatocellular carcinoma (HCC) show significantly poorer survival outcomes than those with compensated liver disease, but a new large multicentre analysis suggests a clinically meaningful subset may still benefit from first-line atezolizumab/bevacizumab combination therapy.
Across 1,499 patients treated between 2020 and 2024, 16.4% Child-Pugh B cirrhosis. In this group, median overall survival was 8.1 months compared with 16.8 months in Child-Pugh A patients, alongside shorter progression-free survival of 5.2 versus 8.6 months. Two-year survival also differed substantially, at 20%versus 38% respectively.
Immunotherapy Outcomes Versus Sorafenib in Child-Pugh B HCC
Those within the Child-Pugh B HCC cohort treated with atezolizumab/bevacizumab experienced longer overall survival than patients receiving sorafenib treatment (p = 0.002), reinforcing potential benefit despite advanced liver impairment.
Combination immunotherapy regimens such as atezolizumab/bevacizumab are now standard first-line options in unresectable HCC, following survival gains demonstrated in earlier trials; however, these pivotal studies excluded patients with Child-Pugh B status.
Real-world evidence therefore remains critical, particularly as Child-Pugh B patients represent a heterogeneous group spanning B7 to B9 severity classes and varying Albumin–Bilirubin (ALBI) grades.
ALBI Stratification Refines Prognostic Insight
A key finding was the ability of a combined ALBEX score, integrating ALBI grade and metastatic status, to stratify Child-Pugh B patients into distinct prognostic categories. Median survival ranges from 10.3 months in the most favourable group to 4.2 months in the poorest.
Patients with ALBI grade 1 or 2 and no extrahepatic metastasis appeared most likely to derive benefit from atezolizumab/bevacizumab, highlighting a potentially actionable selection framework for clinicians managing advanced liver cancer.
Liver Function Dynamics and Clinical Implications
Improvement in liver function occurred in around 31% of Child-Pugh B patients, and was linked to recent treatment of underlying chronic liver disease as well as radiological disease control. Both tumour response and liver function improvement were associated with reduced mortality risk.
Despite these encouraging signals, outcomes remain inferior overall in Child-Pugh B hepatocellular carcinoma, underscoring the need for refined patient selection using ALBI-based stratification and dynamic liver function assessment.
Refining Treatment Pathways in Advanced Liver Disease
The findings suggest that while Child-Pugh B status remains a marker of poor prognosis, it should not be viewed as a uniform exclusion from combination immunotherapy. Instead, integrating ALBI grade, metastatic burden, and dynamic liver function changes may better identify patients who can meaningfully benefit.
Prospective validation is needed, but the study points towards a more individualised approach in advanced hepatocellular carcinoma, where optimisation of liver health alongside systemic therapy could become an important therapeutic strategy.
Reference
Odent AV et al. Clinical predictors of response to atezolizumab-bevacizumab in Child-Pugh B patients with hepatocellular carcinoma. JHEP Rep. 2026;DOI:10.1016/j.jhepr.2026.101915.
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