Predictors of esophago-gastric varices and variceal bleeding in patients receiving atezolizumab/bevacizumab for unresectable hepatocellular carcinoma.

Atezolizumab/bevacizumab (atezo/bev) is a standard treatment for unresectable hepatocellular carcinoma (HCC). Bevacizumab may increase the risk of bleeding, causing concerns of variceal bleeding in patients with cirrhosis. Assess the predictors of esofago-gastric varices, high-risk varices (according to the Baveno criteria), and variceal bleeding in a population receiving atezo/bev for HCC. Analysis of prospectively collected data from 15 Italian centers included in the ARTE database (March 2022-June2024). Logistic regressions were run for predictors of varices amongst patients who had received an upper-gastrointestinal endoscopy (UGE) <6 months before starting treatment. Competing-risk analyses were performed to assess the predictors of variceal bleeding. Among 317 patients treated with atezo/bev included in the ARTE database, 256 had a recently performed UGE and were considered for this study. The main characteristcs of the study population were: median age 70 years, 83% male, 58% viral etiology, 88% Child-Pugh A, 52% ALBIgrade 1, 34.3% neoplastic portal vein thrombosis (nPVT), 59.9% Barcelona Clinic Liver Cancer-C stage. At treatment start, 27.3% of patients were receiving non-selective beta-blockers, and 5.8% had received a prior elastica band ligation. The prevalence of any-type and high-risk varices was 32.0 and 8.6%, respectively. Independent predictors of varices were: platelet count < 150.000/mmc (OR 3.69, 95%CI 2.06-6.61), ALBI grade >1 (OR 1.95, 95%CI 1.09-3.48), and nPVT (OR 1.78, 95%CI 1.01-3.18). High risk varices were independently associated platelet count < 150.000/mmc (OR 5.81, 95%CI 1.91-17.67) and ALBI grade >1 (OR 2.44, 95% CI 1.02-5.77). Nine patients had variceal bleeding during the follow-up (G3: n=6; G4: n=2; G5: n=1), accounting for a 3.5% 12-month cumulative incidence. Amongst patients with varices, high-risk varices were the only factor associated with bleeding (sHR 4.06, 95% CI 1.14-14.46) at the competing risk analysis. In these patients the 12-month risk was 12.7%. The risk of variceal bleeding was low, but non negligible in the subgroup of patients with high-risk varices at baseline. UGE should be performed in all patients before starting treatment: patients with platelet count < 150.000/mmc, ALBI grade > 1 or neoplastic portal vein thrombosis are at increased risk of varices. [ABSTRACT FROM AUTHOR]