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Original Article Downstaging with Atezolizumab-Bevacizumab: A Case Series
Anand V. Kulkarni1orcid , Kumaraswamy P2orcid , Balachandran Menon2orcid , Anuradha Sekaran3orcid , Anuhya Rambhatl4orcid , Sowmya Iyengar1orcid , Manasa Alla1orcid , Shantan Venishetty1orcid , Sumana Kolar Ramachandra2orcid , Premkumar G V4orcid , Mithun Sharma1orcid , P. N Rao1orcid , Duvvur Nageshwar Reddy1orcid , Amit G. Singal5orcid

DOI: https://doi.org/10.17998/jlc.2024.05.12 [Accepted]
Published online: May 27, 2024
1Department of Hepatology, AIG Hospitals, Hyderabad, India
2Department of Liver Transplant Surgery, AIG Hospitals, Hyderabad, India
3Department of Pathology, AIG Hospitals, Hyderabad, India
4Department of Liver Transplant Anaesthesia, AIG Hospitals, Hyderabad, India
5Department of Medicine, UT Southwestern Medical Centre, Dallas, Texas, USA
Corresponding author:  Anand V. Kulkarni,
Email: anandvk90@gmail.com
Received: 3 April 2024   • Revised: 10 May 2024   • Accepted: 12 May 2024
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Background/aims
Hepatocellular carcinoma (HCC) is generally diagnosed at an advanced stage, which limits curative treatment options for these patients. Locoregional therapy (LRT) is the standard approach to bridge and downstage unresectable HCC (uHCC) for liver transplantation (LT). Atezolizumab-bevacizumab (atezo-bev) can induce objective responses in nearly one-third of patients; however, the role and outcomes of downstaging using atezobev remains unknown.
Methods
In this retrospective single-center study, we included consecutive patients between November 2020 and August 2023, who received atezo-bev with or without LRT and were subsequently considered for resection/LT after downstaging.
Results
Of the 115 patients who received atezo-bev, 12 patients (10.4%) achieved complete or partial response and were willing to undergo LT; they (age: 58.5 years; women-17%; Barcelona Clinic Liver Cancer Stage System B/C:5/7) had received 3–12 cycles of atezo-bev, and 4 of them had received prior LRT. Three patients died before LT, while three were awaiting LT. Six patients underwent curative therapies: four underwent living donor LT after a median of 79.5 (54–114) days following the last atezo-bev dose, one underwent deceased donor LT 38 days after the last dose, and one underwent resection. All but one patient had complete pathologic response with no viable HCC. Three patients experienced wound healing complications, and one required re-exploration and succumbed to sepsis. After a median follow-up of 10 (4–30) months, none of the alive patients developed HCC recurrence or graft rejection.
Conclusions
Surgical therapy, including LT, is possible after atezo-bev therapy in wellselected patients after downstaging.

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JLC : Journal of Liver Cancer