Background & aims: Hepatic decompensation is a major event in patients with unresectable hepatocellular carcinoma treated with systemic therapy. Early identification of high-risk patients is essential. The aim of the study was to develop a simple score to predict decompensation in patients treated with atezolizumab plus bevacizumab. Methods: This study enrolled 453 patients from the Atezolizumab-Bevacizumab Real-Life Experience for Treatment of Hepatocellular Carcinoma database (atezolizumab plus bevacizumab first-line, Child-Pugh A). External validation cohort included 292 patients from the atezolizumab plus bevacizumab-real database. Independent predictors derived from Cox regression were combined into a weighted score and operationalized as a point-based algorithm. Patients were then stratified into low-, intermediate-, and high-risk groups. Results: In the Atezolizumab-Bevacizumab Real-Life Experience for Treatment of Hepatocellular Carcinoma (ARTE) database, 74 (16.3%) patients developed hepatic decompensation (median follow-up, 14 months). Neoplastic portal vein thrombosis (hazard ratio, 1.97; 95% confidence interval, 1.20-3.23; P = .007), elevated bilirubin (hazard ratio, 2.61; 95% confidence interval, 1.52-4.47; P < .001), and low platelets (hazard ratio, 1.82; 95% confidence interval, 1.07-3.10; P = .026) were independent predictors, and they were incorporated into the ARTE score. Patients were categorized as low- (0-1 points; n = 360), intermediate- (2 points; n = 49), or high-risk (3-4 points; n = 44). Intermediate-risk patients had a 1.96-fold decompensation risk (P = .038), and high-risk patients a 4.28-fold risk (P < .001), compared with low-risk patients. Significant separation of decompensation-free survival across groups was observed (P < .001), with good discrimination (Harrell's C = 0.7022). Decompensation-free survival at 12 and 24 months was 87% and 83% for low-risk, 79% and 64% for intermediate-risk, and 57% and 56% for high-risk patients, respectively. The ARTE score retained prognostic value in the atezolizumab plus bevacizumab-real cohort (hazard ratio, 1.78; P = .009). Conclusions: The ARTE score is an easy-to-use tool to predict hepatic decompensation in unresectable hepatocellular carcinoma, aiding clinical decision-making.
Predicting Decompensation in Unresectable Hepatocellular Carcinoma on Atezolizumab Plus Bevacizumab: The ARTE Score / Canova, L., Alimenti, E., Argiento, L., Cabibbo, G., Tovoli, F., Di Giacomo, E., Galle, P.R., Celsa, C., Pinter, M., Marron, T.U., Vivaldi, C., Dalbeni, A., Marra, F., Palloni, A., Lonardi, S., Ponziani, F.R., Federico, P., Saeed, A., Pillai, A., Pressiani, T., et al.. - In: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY. - ISSN 1542-3565. - ELETTRONICO. - ??:(2026), pp. 0-0. [10.1016/j.cgh.2026.04.033]
Predicting Decompensation in Unresectable Hepatocellular Carcinoma on Atezolizumab Plus Bevacizumab: The ARTE Score
Marra, Fabio;
2026
Abstract
Background & aims: Hepatic decompensation is a major event in patients with unresectable hepatocellular carcinoma treated with systemic therapy. Early identification of high-risk patients is essential. The aim of the study was to develop a simple score to predict decompensation in patients treated with atezolizumab plus bevacizumab. Methods: This study enrolled 453 patients from the Atezolizumab-Bevacizumab Real-Life Experience for Treatment of Hepatocellular Carcinoma database (atezolizumab plus bevacizumab first-line, Child-Pugh A). External validation cohort included 292 patients from the atezolizumab plus bevacizumab-real database. Independent predictors derived from Cox regression were combined into a weighted score and operationalized as a point-based algorithm. Patients were then stratified into low-, intermediate-, and high-risk groups. Results: In the Atezolizumab-Bevacizumab Real-Life Experience for Treatment of Hepatocellular Carcinoma (ARTE) database, 74 (16.3%) patients developed hepatic decompensation (median follow-up, 14 months). Neoplastic portal vein thrombosis (hazard ratio, 1.97; 95% confidence interval, 1.20-3.23; P = .007), elevated bilirubin (hazard ratio, 2.61; 95% confidence interval, 1.52-4.47; P < .001), and low platelets (hazard ratio, 1.82; 95% confidence interval, 1.07-3.10; P = .026) were independent predictors, and they were incorporated into the ARTE score. Patients were categorized as low- (0-1 points; n = 360), intermediate- (2 points; n = 49), or high-risk (3-4 points; n = 44). Intermediate-risk patients had a 1.96-fold decompensation risk (P = .038), and high-risk patients a 4.28-fold risk (P < .001), compared with low-risk patients. Significant separation of decompensation-free survival across groups was observed (P < .001), with good discrimination (Harrell's C = 0.7022). Decompensation-free survival at 12 and 24 months was 87% and 83% for low-risk, 79% and 64% for intermediate-risk, and 57% and 56% for high-risk patients, respectively. The ARTE score retained prognostic value in the atezolizumab plus bevacizumab-real cohort (hazard ratio, 1.78; P = .009). Conclusions: The ARTE score is an easy-to-use tool to predict hepatic decompensation in unresectable hepatocellular carcinoma, aiding clinical decision-making.
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