Alcohol-related Hepatocellular Carcinoma in the Era of Immunotherapy: Clinical Impact of Atezolizumab Plus Bevacizumab

Alcohol-related liver disease has emerged as a major driver of hepatocellular carcinoma worldwide, reflecting the changing epidemiology of chronic liver disease. Hepatocellular carcinoma arising in the context of chronic alcohol exposure develops within a pro inflammatory and immunosuppressive microenvironment, raising concerns regarding responsiveness to immune based therapies. The combination of atezolizumab, a programmed death ligand 1 inhibitor, and bevacizumab, an anti vascular endothelial growth factor antibody, has become the standard first line systemic treatment for advanced hepatocellular carcinoma after demonstrating superior survival outcomes compared with sorafenib in a pivotal phase III trial. Although patients with alcohol related disease were underrepresented in randomized clinical trials, accumulating evidence from post hoc analyses and real world studies suggests that atezolizumab plus bevacizumab provides clinically meaningful benefit in alcohol related hepatocellular carcinoma, particularly in patients with preserved liver function and adequately controlled portal hypertension. This review synthesizes current evidence on the pathogenesis, immune landscape, and clinical outcomes of alcohol related hepatocellular carcinoma, with a focus on the efficacy and safety of atezolizumab plus bevacizumab and the importance of Child Pugh status in treatment selection.