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Background <p>Immune checkpoint inhibitors (ICIs) have revolutionized advanced hepatocellular carcinoma (HCC) outcomes in Child-Turcotte-Pugh A (CTP-A) cirrhosis. However, 30–40% of real-world advanced HCC cases involve CTP-B cirrhosis, yet are excluded from pivotal trials, representing a substantial unmet need.</p> Methods <p>Immunotherapy for CTP-B HCC has not yet been comprehensively reviewed. This narrative review summarizes the latest evidence on ICIs in CTP-B HCC through January 2026, evaluating ICI efficacy, safety, and patient selection algorithms across CTP-B subclasses. We present a balanced perspective on pre-ICI portal hypertension screening/prophylaxis, decompensation triggers/recompensation strategies, immune-mediated hepatitis differentiation, locoregional therapy sequencing, and transplant-bridging risks with ICI in the CTP-B patient population.</p> Results <p>ICIs demonstrate modest efficacy with tolerable safety in well-selected CTP-B7-B8 HCC patients, but require liver-centric considerations to mitigate the risk of decompensation. We propose liver-centric trial endpoints and a multidisciplinary (oncology-hepatology-transplant) framework to improve outcomes in this hard-to-treat population, and to include CTP-B HCC patients in clinical trials to address evidence gaps.</p> Conclusions <p>This review provides comprehensive guidance on ICIs for CTP-B HCC, identifying key clinical practices and knowledge gaps to inform real-world use and future research.</p>

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Immune-checkpoint inhibitors for advanced hepatocellular carcinoma in Child–Turcotte–Pugh-B cirrhosis: a liver-centric approach to outcomes beyond tumor progression

  • 期刊论文

  • 发表日期：

    2026年5月22日

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  • Dhiraj Agrawal,
  • Dinesh Jothimani,
  • Sherrie Bhoori,
  • Guru N. Reddy,
  • Sanjiv Saigal,
  • Mohamed Rela,
  • Vincenzo Mazzaferro

摘要

Background

Immune checkpoint inhibitors (ICIs) have revolutionized advanced hepatocellular carcinoma (HCC) outcomes in Child-Turcotte-Pugh A (CTP-A) cirrhosis. However, 30–40% of real-world advanced HCC cases involve CTP-B cirrhosis, yet are excluded from pivotal trials, representing a substantial unmet need.

Methods

Immunotherapy for CTP-B HCC has not yet been comprehensively reviewed. This narrative review summarizes the latest evidence on ICIs in CTP-B HCC through January 2026, evaluating ICI efficacy, safety, and patient selection algorithms across CTP-B subclasses. We present a balanced perspective on pre-ICI portal hypertension screening/prophylaxis, decompensation triggers/recompensation strategies, immune-mediated hepatitis differentiation, locoregional therapy sequencing, and transplant-bridging risks with ICI in the CTP-B patient population.

Results

ICIs demonstrate modest efficacy with tolerable safety in well-selected CTP-B7-B8 HCC patients, but require liver-centric considerations to mitigate the risk of decompensation. We propose liver-centric trial endpoints and a multidisciplinary (oncology-hepatology-transplant) framework to improve outcomes in this hard-to-treat population, and to include CTP-B HCC patients in clinical trials to address evidence gaps.

Conclusions

This review provides comprehensive guidance on ICIs for CTP-B HCC, identifying key clinical practices and knowledge gaps to inform real-world use and future research.