11 12 This promotes antitumor response in T cells and prevents T cell exhaustion. 10 This led to many successful immunotherapy trials for the treatment of various solid tumors, with the main targets for immune checkpoint blockade being PD-1, programmed cell death ligand 1 (PD-L1) and cytotoxic T lymphocyte-associated antigen 4 (CTLA-4). There has been an increased interest in immunotherapy due to the success of a programmed cell death protein 1 (PD-1) blockade trial for the treatment of advanced melanoma. 4 Multiple second line therapies were developed for patients receiving first line sorafenib therapy (including regorafenib, cabozantinib, and ramucirumab), 7–9 but the optimal management of patients progressing on first line bevacizumab and atezolizumab remains unclear. 5 6 However, the prognosis for patients treated with modern systemic therapy continues to lag many other tumor types, with a median progression-free survival of 6.8 months and a medial overall survival of 19 months. This combination is associated with improved overall survival, progression-free survival, and quality of life than the historical standard of care, sorafenib. 4 Since 2020, the preferred first-line treatment for patients with advanced HCC (aHCC) with preserved liver function is the combination of atezolizumab (anti-PD-L1) and bevacizumab (anti-vascular endothelial growth factor).

2 It is the third-leading cause of cancer-related death worldwide 3 and despite efforts to screen at-risk individuals, approximately 80% of patients are diagnosed at late stages when curative intervention (ie, surgical resection or transplantation) is no longer possible. 1 HCC is caused by chronic infection of hepatitis B or C virus, excess alcohol consumption, diabetes, obesity, and ingestion of aflatoxin-contaminated food. Hepatocellular carcinoma (HCC) is the most common type of liver cancer, accounting for approximately 80% of primary liver malignancies.

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