Tislelizumab plus tyrosine kinase inhibitors with TACE improves survival in unresectable hepatocellular carcinoma with clinical predictors and manageable safety.

[BACKGROUND & AIMS] The survival benefit of adding transarterial chemoembolization (TACE) to systemic therapy (tislelizumab plus tyrosine kinase inhibitors [TKIs]) for unresectable hepatocellular carcinoma (HCC) requires validation. This retrospective study compared the efficacy and safety of tislelizumab-TKIs with or without TACE and identified clinical predictors of benefit.

[METHODS] This retrospective analysis included 283 unresectable HCC patients: systemic therapy alone (STG, n=98; tislelizumab plus TKIs) versus combination therapy (CTG, n=185; tislelizumab plus TKIs and TACE). Primary endpoints were overall survival (OS) and progression-free survival (PFS), analyzed by Cox regression. Propensity score matching (PSM) was used to reduce baseline differences between the two groups.

[RESULTS] After PSM, CTG significantly improved median OS (22.5 [95% confidence interval (CI): 19.0-34.4] . 14.0 [12.1-18.6] months; hazard ratio (HR) 0.53, p<0.001) and PFS (14.6 [12.1-19.1] . 9.5 [7.8-12.5] months; HR 0.59, p<0.001) versus STG. Multivariate analysis identified independent predictors of poor OS: age <60 years, extrahepatic spread, portal vein thrombus, alpha-fetoprotein (AFP) ≥400 ng/mL, and elevated gamma-glutamyl transferase (GGT). Subgroups with maximal CTG benefit included patients aged ≥60 years, no extrahepatic spread, AFP <400 ng/mL, and normal GGT. CTG had higher all-grade adverse events (79.6% . 67.0%, p=0.021) and grade ≥3 events (23.5% . 14.1%, p=0.038), primarily manageable liver toxicity and hematological abnormalities.

[CONCLUSION] Combining TACE with tislelizumab-TKIs significantly improves survival over systemic therapy alone in unresectable HCC, with maximal benefit observed in patients aged ≥60 years, without extrahepatic spread, with AFP <400 ng/mL, or normal GGT, despite increased manageable toxicity.