Assessing Vascular Invasion and Bleeding Risk in Advanced HCC

This segment explores the real-world challenges of evaluating vascular invasion and bleeding risk when selecting systemic therapy for patients with advanced HCC, particularly those with underlying or previously undiagnosed cirrhosis. Dr. Braiteh opens the discussion by asking how concerns such as major vascular invasion and unrecognized esophageal varices influence frontline decision-making, especially in patients presenting for the first time with multiple concurrent liver-related conditions.

Dr. Akçe explains that this scenario is frequently encountered in routine practice and requires careful baseline assessment. He emphasizes the importance of esophagogastroduodenoscopy (EGD), particularly in patients with cirrhosis or portal hypertension, noting that untreated varices significantly increase bleeding risk. Drawing on the IMbrave150 trial experience, Dr. Akçe highlights that variceal screening and appropriate management were mandatory due to the use of antiangiogenic therapy. In patients with high-risk or non-eradicable varices, he often avoids atezolizumab plus bevacizumab and instead favors immune checkpoint inhibitor–based regimens that do not carry the same bleeding risk.

The conversation also addresses the clinical implications of main portal vein invasion. Dr. Akçe reviews how key frontline trials differed in their eligibility criteria, with some studies excluding patients with main portal vein invasion, whereas others included a limited proportion of this population. Although regulatory approvals do not formally exclude these patients, he notes that vascular invasion remains an important prognostic factor and may influence both outcomes and safety considerations in practice.

Dr. Braiteh reinforces the importance of understanding clinical trial design and exclusions, particularly for a broad oncology audience. He underscores that most studies enrolled patients with Child-Pugh A liver function, which may not fully reflect everyday practice. Both experts stress that comprehensive evaluation, including variceal screening, remains standard of care, with the ultimate goal of treating the whole patient, not just the cancer.