Risk Factors for the Exacerbation of Esophageal Varices in Patients Receiving Atezolizumab plus Bevacizumab Therapy for Unresectable Hepatocellular Carcinoma.

[INTRODUCTION] Atezolizumab plus bevacizumab (AB) therapy is an effective systemic therapy for unresectable hepatocellular carcinoma (u-HCC). However, exacerbations of esophageal varices (EV) often occur, and EV management should be clarified to attain a better prognosis in patients with u-HCC. Our research aimed to explore the actual situation of EV exacerbation and its risk factors in patients receiving AB therapy.

[METHODS] We recruited 82 patients receiving AB therapy for u-HCC. All patients underwent esophagogastroduodenoscopy (EGD) within 3 months before AB induction to assess EV presence. The emergence of EV findings requiring urgent or planned endoscopic treatment defined EV exacerbation. The frequency and risk factors for EV exacerbation after AB introduction were analyzed.

[RESULTS] Of the participants, 49% had EV findings on preinduction EGD. Within the observation period, 17% had EV exacerbation, and 7.2% experienced rupture. Among those with EV exacerbation, 7 had positive red color signs, and 1 had formal deterioration to F3. In EV rupture, 4 had eruptive hemorrhage, 1 had gushing hemorrhage, and 1 had a white plug. Independent factors requiring therapeutic intervention for EV exacerbation were EV treatment history, drug-resistant ascites effusion, esophageal intramural vessel (EIV) diameter >3.3 mm, and left gastric vein (LGV) diameter >4.9 mm on computed tomography (CT) scan.

[CONCLUSION] Patients with EV treatment history, drug-resistant ascites effusion, and EIV and LGV diameters >3.3 and 4.9 mm via CT, respectively, may require careful monitoring for possible EV exacerbation, enabling better EV management, adequate AB therapy, and finally, prolonged patient survival.