Liver Stiffness Measured by Vibration-Controlled Transient Elastography Predicts Hepatic Decompensation in Patients with Hepatocellular Carcinoma Receiving Systemic Treatments

Background/Aims: Hepatic decompensation (HD) following systemic treatment, including atezolizumab + bevacizumab (Atezo/Bev) and tyrosine kinase inhibitors (TKIs), is a critical prognostic event in advanced hepatocellular carcinoma (HCC). This study aimed to evaluate the predictive utility of liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) for HD incidence post-treatment. Methods: This multicenter study included 396 HCC patients who received systemic therapy (Atezo/Bev or TKIs) and underwent VCTE prior to treatment at seven university-affiliated hospitals. Clinical outcomes including HD independent of tumor progression, variceal bleeding (VB), overall survival (OS), and progression-free survival (PFS) were assessed. A 25 kPa LSM threshold, based on Baveno VII criteria, stratified patients into high and low LSM groups. Results: Of the 396 patients, 176 received Atezo/Bev, while 45 and 175 received lenvatinib and sorafenib, respectively. Treatment distribution was similar between high and low LSM groups (p = 0.546). High LSM was associated with increased HD risk (HR = 3.00, p < 0.001), VB risk (HR = 2.34, p = 0.048), and a trend toward worse OS (HR = 1.27, p = 0.065). In the low LSM group, Atezo/Bev outperformed TKIs in OS and PFS (p < 0.05) without increasing HD risk. In contrast, in the high LSM group, Atezo/Bev and TKIs showed no OS or PFS differences, but Atezo/Bev significantly increased HD and VB risk (p < 0.05). A risk score based on four variables (Child-Pugh score 5, LSM ≥25 kPa, multiple tumors, and high-grade portal vein tumor thrombosis) showed good predictive accuracy for HD at 12 months (AUC = 0.832) and effectively identified patients at high risk for HD, VB, and poor survival (p < 0.005). Conclusion: LSM by VCTE predicts HD following systemic treatment in advanced HCC. In patients with high LSM, Atezo/Bev increases HD risk, warranting careful treatment selection.