Impact of Child Pugh B Stage for the Treatment of Advanced HCC

Patients with hepatocellular carcinoma (HCC) and moderate liver dysfunction (Child-Pugh class B) represent a large yet understudied population. These patients are frequently excluded from clinical trials, leading to a paucity of evidence regarding optimal management. The Child-Pugh score, although historically central for therapeutic decision-making, has major limitations due to interrelated and subjective parameters. The introduction of objective indices such as the albumin-bilirubin (ALBI) grade has improved functional assessment and allowed a more refined stratification within the heterogeneous CP-B group. This review summarizes and critically discusses current data on locoregional and systemic treatments for HCC in CP-B patients. Available evidence suggests that transarterial chemoembolization (TACE) and selective internal radiation therapy (SIRT) may be feasible in carefully selected and well-compensated CP-B7 patients, particularly those with ALBI grade 1-2 and controlled portal hypertension, with median overall survival ranging approximately from 12 to 16 months. In contrast, patients with CP-B8/B9 liver function experience significantly higher rates of hepatic decompensation and derive limited survival benefit from locoregional interventions. Similarly, systemic therapies may be considered in selected CP-B7 patients. Tyrosine kinase inhibitors remain an option for patients ineligible for immunotherapy or as sequential therapy after immune checkpoint inhibitors, though benefits are modest and toxicity frequent in CP-B8/9. The integration of dynamic liver function monitoring and more objective tools may pave the way toward more personalized therapeutic strategies. Dedicated clinical trials focusing on CP-B HCC are urgently needed to optimize treatment selection, sequencing, dosing, and safety in this fragile but growing patient population.