Are you comfortable using durvalumab + tremelimumab in advanced HCC with portal vein thrombus, when these patients were not included in the HIMALAYA trial?

Main portal vein thrombus (Vp4) has consistently been associated with poor prognosis, and prevalence can range from 20-44% in HCC within 1-3 years of diagnosis (Abdelhamed et al., PMID 39957750). Prior to 2020 and the advent of immunotherapy in the first line, median OS is around 2-5 months. In many of the current first-line trials, including HIMALAYA and CheckMate 9DW, Vp4 is an exclusion criterion, while IMbrave150 included patients with Vp4 (48 patients in the atezo/bev arm vs 25 in the sorafenib arm). The median OS was 7.6 vs 5.5 months (HR, 0.62; 95% CI: 0.34, 1.11) and median PFS 5.4 vs 2.8 months (HR, 0.62; 95% CI: 0.35, 1.09). All-grade variceal bleeding was higher with atezo + bev in Vp4 (13.6%) vs the rest of the ITT patients (2.5...