Breaking Barriers for Intensive Care Admission in Patients With Advanced HCC on Immunotherapy

Background and Aims: Intensive Care Unit (ICU) admission is usually denied to patients with advanced hepatocellular carcinoma (HCC) due to the perceived poor prognosis associated with both cirrhosis and liver cancer. However, immunotherapy based on immune checkpoint inhibitors (ICI) has transformed the treatment landscape, and the role of critical care is becoming more relevant in managing adverse events. We aim to assess the outcome of patients with advanced HCC treated with ICI admitted to the ICU. Methods: We evaluated patients treated with ICI combinations across 20 medical centres globally between November 2012 and April 2024. Demographic data, ICI types, causes of admission, organ support, and mortality in the short and medium term were recorded. Results: Of 1065 patients, 47 (4.4%) were admitted to the ICU. Most were male (76.6%) with cirrhosis (93.6%), and 59.7% received ICI as first-line therapy. The primary reasons for ICU admission were immune-related adverse events (irAE) in 46.8% and variceal bleeding in 29.8%. The median time to ICU admission was 115 days [IQR 38–202] after the initiation of ICI treatment. Among patients admitted due to irAEs, the median time was 51 days [IQR 31–137]. ICU mortality was 25.5%. Two-thirds were alive 28 days post-ICU discharge, with 3- and 6-month survival rates of 83% and 69%. Of the 61.3% of survivors, they were rechallenged with ICI or started new HCC therapy. Conclusions: irAEs are the main cause of ICU admission in patients with advanced HCC receiving ICI. Despite the severity, 66% were discharged, and nearly half resumed treatment. These findings highlight the vital role of ICU care in managing HCC patients, challenging the notion of denying them intensive care.