Impact of atezolizumab plus bevacizumab on the aggravation of esophageal varices in patients with unresectable hepatocellular carcinoma

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Objective: Serious adverse events such as gastrointestinal variceal bleeding have been reported in patients treated with atezolizumab plus bevacizumab (ATZ/BV) for unresectable hepatocellular carcinoma (uHCC). This study aimed to identify factors associated with the aggravation of esophageal varices (EV) in these patients.

Methods: This retrospective study included 67 patients with uHCC who received ATZ/BV. Blood flow volume in the portal vein (PVVo) was measured using ultrasonography before and after treatment. The total shunt diameter (TSD) of three collateral veins, the left gastric, posterior gastric, and short gastric veins, and splenic volume (SV) were assessed using computed tomography. EV were evaluated by esophagogastroduodenoscopy both before and after treatment, and patients were categorized into aggravation and nonaggravation groups. Logistic regression analysis was performed to identify factors associated with EV aggravation.

Results: EV aggravation occurred in 22 patients (33%). Compared with the nonaggravation group, the aggravation group showed significantly greater increases in TSD and SV and smaller changes in PVVo. Multivariate analysis identified increases in TSD and SV above thresholds of 19.3% and 9.4%, respectively, as significant factors contributing to EV aggravation.

Conclusions: Patients showing increased TSD and SV after ATZ/BV therapy require careful monitoring and management of esophageal varices.