Safety and Efficacy of PD-1 inhibitors plus Tyrosine kinase inhibitors Combination Therapy in Patients with Advanced Hepatocellular Carcinoma Combined with Hyperbilirubinemia: A Retrospective Cohort Study

Shida Pan ^1,2 Jianing Wang ^2,3 Jiahe Tian ^2,3 Yilin Wang ^2,4 Siyu Wang ² Yingying Yu ^2,5 Fengyi Li ² Yan-Mei Jiao ² Yingjuan Shen ² Luo Yang ² Xiaomeng Liu ² Qin Qiu ² Junqing Luan ² Fu-Sheng Wang ^1,2* Fanping Meng ^2,3,4*

• ¹ Beijing Ditan Hospital, Capital Medical University, Beijing, Beijing Municipality, China
• ² Senior Department of Infectious Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
• ³ 302 Clinical Medical College, Peking University, Beijing, Beijing Municipality, China
• ⁴ Chinese PLA Medical School, Beijing, China
• ⁵ Division of Life Sciences and Medicine, The First Affiliated Hospital of University of Science and Technology of China Anhui Provincial Hospital, Hefei, Anhui Province, China

Background: Programmed death-1 (PD-1) inhibitors plus tyrosine kinase inhibitors (TKIs) combination therapy are considered as a first-line treatment recommendation for advanced hepatocellular carcinoma (HCC). However, patients with hyperbilirubinemia are excluded from this therapeutic option due to limitations in indications. There is a notable absence of published studies evaluating the safety and efficacy of the PD-1 inhibitors plus TKIs combination therapy in patients with HCC combined with hyperbilirubinemia.Methods: Patients with HCC complicated with hyperbilirubinemia who received combination therapy with PD-1 inhibitors and TKIs were retrospectively analyzed. Adverse events, tumor response, and laboratory parameters were recorded to assess the safety and efficacy of the treatment, as well as to identify potential risk factors influencing survival.Results: A total of 108 participants were included in the study, with 56 patients (51.9%) reporting at least one adverse event, the majority of which were mild. The objective response rate (ORR) for the enrolled participants was 11.9%, and the disease control rate(DCR) reached 61.2%. The median overall survival (OS) for the entire cohort was 5.03 months, while the median progression-free survival (PFS) was 3.63 months. Multifactorial analysis showed that MELD score >18 and increased total bilirubin (TBIL) levels within one week were significant risk factors for OS. Patients with a decrease in TBIL levels within one week had significantly prolonged median OS (not reached vs 3.3months, P =0.013) and median PFS (7.03 months vs 2.77 months, P =0.010).Combination therapy demonstrated favorable safety and tolerability among patients with HCC combined with hyperbilirubinemia. Patients who experienced a rapid decline in TBIL levels during the early phase of treatment with PD-1 inhibitors and TKIs were observed to derive clinical benefits. Early initiation of aggressive interventions aimed at reducing TBIL levels is recommended to optimize treatment outcomes.