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OpenOnco · HCC · Child-Pugh A 1L · Atezo+bev (IMbrave150)
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OpenOnco · Treatment Plan
Treatment plan — Hepatocellular carcinoma
PLAN-HCC-IMBRAVE150-001-V1 · v1 · 2026-08-18
Patient
HCC-IMBRAVE150-001 · Algorithm: ALGO-HCC-SYSTEMIC-1L
DiagnosisHepatocellular carcinoma
MOH / ICD-10C22.0
ICD-O-38170/3; C22.0
StageIV

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks
✅ Covered biomarkers (matched in KB)
BiomarkerVariantESCATEvidenceClinical significanceDrugsSources
No clinically actionable variants matched in this profile.
⚠️ Not included in plan
BiomarkerStatus
BIO-AFPBIO definition in KB; no ESCAT BMA entry — verify with clinician
BIO-HBV-STATUSExcluded (negative)
BIO-HCV-STATUSExcluded (negative)

Primary current-line option

Standard plan
★ DEFAULT
Indication
IND-HCC-SYSTEMIC-1L-ATEZO-BEV
Regimen
Atezolizumab + Bevacizumab
Drugs + NSZU
  • Atezolizumab (DRUG-ATEZOLIZUMAB) 1200 mg · IV q3w · IV ⚠ NSZU — not for this indication
  • Bevacizumab (DRUG-BEVACIZUMAB) 15 mg/kg · IV q3w (concurrent) · IV ⚠ NSZU — not for this indication
Hard contraindications
CI-PEMBROLIZUMAB-AUTOIMMUNE
Reason
Primary current-line option selected by ALGO-HCC-SYSTEMIC-1L at step 3; branch-driving red flag: RF-FITNESS-ECOG-FIT.

Other current-line alternatives (2 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.
Aggressive plan
Indication
IND-HCC-SYSTEMIC-1L-DURVA-TREME
Regimen
Durvalumab + Tremelimumab (STRIDE)
Drugs + NSZU
  • Tremelimumab (DRUG-TREMELIMUMAB) 300 mg · IV — single priming dose only (cycle 1 day 1) · IV ✗ Not registered in UA
  • Durvalumab (DRUG-DURVALUMAB) 1500 mg · IV q4w (cycle 1 with tremelimumab; subsequent cycles mono) · IV ⚠ NSZU — not for this indication
Hard contraindications
CI-PEMBROLIZUMAB-AUTOIMMUNE
Reason
Current-line alternative presented for HCP consideration
Standard plan
Indication
IND-HCC-SYSTEMIC-1L-SORAFENIB
Regimen
Sorafenib monotherapy
Drugs + NSZU
  • Sorafenib (DRUG-SORAFENIB) 400 mg PO BID (start 200 mg BID; escalate to 400 mg if tolerated) · Continuous · PO ⚠ NSZU — not for this indication
Reason
Current-line alternative presented for HCP consideration

Why this branch was chosen

Triggers from the patient profile that fired and drove the chosen branch.
Step 3 → branch IND-HCC-SYSTEMIC-1L-ATEZO-BEV
  • RF-FITNESS-ECOG-FIT ★ winner: Fit performance status (ECOG 0-1): patient is fully active or restricted in physically strenuous activity but ambulatory and able to carry out light work. Eligible for full-dose chemotherapy and intensive regimens (CHOEP, BEACOPP-escalated, HD-MTX, ASCT consolidation, CAR-T). SRC-NCCN-BCELL-2025SRC-ESMO-DLBCL-2024

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks
IDNamePriorityCategoryWhere to orderNeeded for
TEST-AFPAFP serumCriticallabCSD Lab: B001all tracks
TEST-CHILD-PUGH-CALCULATIONChild-Pugh classification calculationCriticalclinical_assessment—all tracks
TEST-CT-CHEST-ABDOMEN-PELVISCT chest + abdomen + pelvis with IV contrastCriticalimaging—all tracks
TEST-EGD-VARICES-SCREENINGEsophagogastroduodenoscopy with varices assessmentCriticalimaging—standard
TEST-HBV-SEROLOGYHepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)Criticallab—standard
TEST-HCV-ANTIBODYHCV AntibodyCriticallab—standard
TEST-LFTLiver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)Criticallab—standard

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track
  • Patient with active or incompletely controlled pre-existing autoimmune or inflammatory disease (sarcoidosis, rheumatoid arthritis, IBD, SLE, autoimmune hepatitis, inflammatory myopathy, myasthenia gravis, or similar) is considered for immune checkpoint inhibitor (ICI) therapy — elevated risk of immune-related adverse events (irAE) flare or de-novo grade 3-4 irAE. Requires specialist (rheumatology / pulmonology / gastroenterology) pre-treatment review; prefer lower-irAE-burden backbone when options exist (pembrolizumab mono > ipilimumab+nivolumab).
    Pre-existing autoimmune disease is present in ~10-15% of patients eligible for ICI therapy; historically excluded from pivotal trials. Real-world data (Abdel-Wahab 2018, 3557 pts) shows 55% experienced irAE flare and ~29% required…
    RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISKSRC-SITC-ICI-IRAEMANAGEMENT-2021SRC-ESMO-ICI-TOXICITY-2022
  • Child-Pugh B or C cirrhosis in HCC patient. CP-A is the only fully- studied class for ICI combinations (atezo+bev, durva+treme); CP-B has partial sorafenib/lenvatinib data but worse safety; CP-C generally precludes systemic therapy (focus on supportive care + transplant evaluation if liver-limited disease).
    Child-Pugh score assesses encephalopathy, ascites, bilirubin, albumin, INR. CP-B: ICI-bev contraindicated (anti-angiogenic stress on decompensated liver); sorafenib partial data (GIDEON registry). CP-C: best supportive care + hepatology /…
    RF-HCC-CHILD-PUGH-B-CSRC-NCCN-HCC-2025SRC-AASLD-HCC-2023
  • Active or recent (≤6 months) variceal hemorrhage in HCC patient with cirrhosis. Mandates EGD assessment + variceal band ligation BEFORE any bevacizumab-containing regimen (atezo+bev, IMbrave150 prerequisite). Active bleeding is an absolute hold on systemic therapy until controlled.
    IMbrave150 explicitly excluded patients with high-risk varices not treated by ligation/banding. Routes patient to durva+treme (STRIDE) alternative (HIMALAYA — no bev exposure) OR to TKI (sorafenib / lenvatinib) alone if anti-angiogenic…
    RF-HCC-VARICEAL-BLEEDSRC-NCCN-HCC-2025SRC-AASLD-HCC-2023

CONTRA-AGGRESSIVE

Hard contraindications to escalation
  • Pembrolizumab (and other PD-1/PD-L1 inhibitors) augment T-cell responses; in patients with active autoimmunity or post-transplant immunosuppression, this can precipitate severe organ-specific flares (colitis, hepatitis, pneumonitis, transplant rejection) that may be fatal or require transplant loss. CI-PEMBROLIZUMAB-AUTOIMMUNE

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity
Standard plan (IND-HCC-SYSTEMIC-1L-ATEZO-BEV)
  • Do NOT initiate without EGD within 6 months — high-risk varices must be ligated/banded first (perforation/bleed risk)
  • Do NOT use in Child-Pugh B/C — atezo+bev not studied; mortality risk
  • Do NOT skip HBV prophylaxis in HBsAg+ / anti-HBc+ patients (entecavir or TDF) — HBV reactivation reported under anti-VEGF + ICI; continue ≥12 mo post-therapy
  • Do NOT delay HCV-DAA in HCV-RNA+ patients — initiate sofosbuvir/velpatasvir before or concurrently with atezo+bev; SVR12 reduces decompensation risk and may improve OS in HCC-on-HCV-cirrhosis
  • Do NOT combine sofosbuvir with amiodarone — severe bradycardia / cardiac arrest
  • Do NOT continue bevacizumab through Grade 3+ HTN or proteinuria >3.5 g/24h
Aggressive plan (IND-HCC-SYSTEMIC-1L-DURVA-TREME)
  • Do NOT use in Child-Pugh B/C
  • Do NOT skip HBV prophylaxis
  • Do NOT continue through Grade 3+ irAE without permanent discontinuation consideration (CTLA-4 colitis can be fatal)
Standard plan (IND-HCC-SYSTEMIC-1L-SORAFENIB)
  • Do NOT continue through hepatic decompensation onset
  • Do NOT delay HFSR prophylaxis (urea cream, emollient, friction avoidance)

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Standard plan

Induction · Atezolizumab + Bevacizumab
21-day cycles × Until progression / unacceptable toxicity

Aggressive plan

Induction · Durvalumab + Tremelimumab (STRIDE)
28-day cycles × Until progression / unacceptable toxicity

MDT brief

Discussion questions (1, 0 blocking)

  • OQ-LDH-CURRENT
    What is the current LDH? Marker of tumor burden and transformation.
    LDH is part of the prognostic indices of indolent lymphomas.
    → hematologist

MDT talk tree (2 steps)

#OwnerTopicAction
1hematologistStaging / disease burden What is the current LDH? Marker of tumor burden and transformation.
2clinical_pharmacistSpecialist review Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (recommended) — for consideration (1)

  • Clinical pharmacist recommended
    Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Data quality

Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.
  • Biomarker coverage: 3/3 known (100%), 0 missing, 0 default-track gaps
  • Unevaluated RedFlags: RF-A1AT-DEFICIENCY-HCC-LUNG-PREVENTION, RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-CASCADE-VHL-FDR-POSITIVE, RF-CHRONIC-CIRRHOSIS-ETIOLOGY-AGNOSTIC-HCC-PREVENTION, RF-CHRONIC-HBV-MALIGNANCY-PREVENTION, RF-CHRONIC-NAFLD-MASLD-HCC-PREVENTION, RF-CHRONIC-T2DM-CANCER-RISK-PREVENTION, RF-HCC-AFP-RAPID-RISE, RF-HCC-FRAILTY-AGE, RF-HCC-HBV-REACTIVATION-RISK, RF-HCC-HIGH-RISK-BIOLOGY, RF-HEMOCHROMATOSIS-HCC-PREVENTION, RF-LIFESTYLE-ALCOHOL-CANCER-PREVENTION, RF-LIFESTYLE-OBESITY-CANCER-PREVENTION, RF-LIFESTYLE-TOBACCO-CANCER-PREVENTION, RF-OCC-VINYL-CHLORIDE-MALIGNANCY-PREVENTION, RF-PSC-CHOLANGIOCARCINOMA-PREVENTION, RF-VHL-CONFIRMED-CARRIER, RF-WILSONS-DISEASE-HCC-PREVENTION
Technical MDT skill metadata (1/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
Specialistskill_idVersionLast reviewedSign-offsDomain
Cellular therapy specialist (CAR-T)cellular_therapy_specialistv0.1.02026-04-250cellular_therapy
Clinical pharmacistclinical_pharmacistv0.1.02026-04-250clinical_pharmacy
Hematologist / oncohematologisthematologistv0.1.02026-04-250hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)hematopathologistv0.1.02026-04-250hematopathology
Infectious disease / hepatologyinfectious_disease_hepatologyv0.1.02026-04-250infectious_diseases
Medical oncologist (solid-tumor chemotherapist)medical_oncologistv0.1.02026-04-250solid_oncology
Molecular geneticist / molecular oncologistmolecular_geneticistv0.1.02026-04-250molecular_oncology
Palliative carepalliative_carev0.1.02026-04-250palliative_care
Pathologist (general)pathologistv0.1.02026-04-250pathology
Primary care / family physicianprimary_carev0.1.02026-04-250primary_care
Psycho-oncologistpsychologistv0.1.02026-04-250psychosocial
Radiation oncologistradiation_oncologistv0.1.02026-04-250radiation_oncology
Radiologistradiologistv0.1.02026-04-250diagnostic_imaging
Social worker / case managersocial_worker_case_managerv0.1.02026-04-250psychosocial
Surgical oncologistsurgical_oncologistv0.1.02026-04-250surgical_oncology
Transplant specialist (BMT)transplant_specialistv0.1.02026-04-250cellular_therapy

Sources cited

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-08-18.
NCTTitlePhaseStatusSponsorUASignalsEligibility (excerpt)
NCT06537908Anti-PD-1/PD-L1 Antibodies Plus Anti-VEGF Antibody Treatment in Patients With Advanced-Stage HCCN/ARECRUITINGShanghai Zhongshan Hospital—Single country
NCT04510129A Multicenter Cancer Biospecimen Collection StudyN/ARECRUITINGCofactor Genomics, Inc.—Single country
NCT04615143Tislelizumab or Tislelizumab Combined With Lenvatinib Neo-adjuvant Treatment for Resectable RHCCPHASE2RECRUITINGSun Yat-sen University—Surrogate endpoint only Single country
NCT06294548A Study of Valemetostat Tosylate (DS-3201b) With Atezolizumab and Bevacizumab in HCCPHASE1 / PHASE2RECRUITINGUniversity of Alabama at Birmingham—Small N (<50) Single country
NCT07337460Efficacy and Safety of Icaritin Combined With mFOLFOX in Postoperative HCC With High-risk Recurrence FactorsPHASE2RECRUITINGNorthern Jiangsu People's Hospital—Small N (<50) Single country
NCT07246668A Phase II Single-Arm Clinical Study to Evaluate the Efficacy and Safety of Carbon Ion Radiotherapy With Atezolizumab and Bevacizumab Combination Therapy in Patients With Advanced Hepatocellular CarcinomaPHASE2RECRUITINGYonsei University—Surrogate endpoint only Single country
NCT07293468Comparison of SBRT and SIRT With Combination IO for Locally-advanced, Unresectable HCCs (BIIRTH)PHASE2 / PHASE3RECRUITINGTuen Mun Hospital—Surrogate endpoint only Single country
NCT06609850The Comparison of TACE-Lenvatinib With TACE-Lenvatinib-ablation for Intermediate Recurrent Hepatocellular CarcinomaNARECRUITINGSun Yat-sen University—Surrogate endpoint only Single country
NCT04340986Cohort of Patients With Hepatocellular Carcinoma or CholangiocarcinomaN/ARECRUITINGAssistance Publique - Hôpitaux de Paris—Single country
NCT06114082TACE Using Idarubicin Versus Doxorubicin Chemoemulsion in Patients with Hepatocellular CarcinomaPHASE2RECRUITINGSeoul National University Hospital—Surrogate endpoint only Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).
OptionUA registrationNSZUCost orientationAccess pathway
Standard plan
Atezolizumab + Bevacizumab (REG-ATEZO-BEV)
✓ registered✓ covered₴-? — verify pathwayNSZU formulary
Aggressive plan
Durvalumab + Tremelimumab (STRIDE) (REG-DURVA-TREME-STRIDE)
1/2 component drug(s) not registered in Ukraine +1
✗ not registered✗ out-of-pocket₴-? — verify pathwaynot recorded
Standard plan
Sorafenib monotherapy (REG-SORAFENIB-MONO)
✓ registered✓ covered₴-? — verify pathwayNSZU formulary
Trial · NCT06537908
Anti-PD-1/PD-L1 Antibodies Plus Anti-VEGF Antibody Treatment in Patients With Advanced-Stage HCC
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT04510129
A Multicenter Cancer Biospecimen Collection Study
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT04615143
Tislelizumab or Tislelizumab Combined With Lenvatinib Neo-adjuvant Treatment for Resectable RHCC
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT06294548
A Study of Valemetostat Tosylate (DS-3201b) With Atezolizumab and Bevacizumab in HCC
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT07337460
Efficacy and Safety of Icaritin Combined With mFOLFOX in Postoperative HCC With High-risk Recurrence Factors
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT07246668
A Phase II Single-Arm Clinical Study to Evaluate the Efficacy and Safety of Carbon Ion Radiotherapy With Atezolizumab and Bevacizumab Combination Therapy in Patients With Advanced Hepatocellular Carcinoma
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT07293468
Comparison of SBRT and SIRT With Combination IO for Locally-advanced, Unresectable HCCs (BIIRTH)
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT06609850
The Comparison of TACE-Lenvatinib With TACE-Lenvatinib-ablation for Intermediate Recurrent Hepatocellular Carcinoma
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT04340986
Cohort of Patients With Hepatocellular Carcinoma or Cholangiocarcinoma
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor
Trial · NCT06114082
TACE Using Idarubicin Versus Doxorubicin Chemoemulsion in Patients with Hepatocellular Carcinoma
No UA site listed — international referral required
— unknown— unknown
self-pay: ₴0/course
Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-08-18.

plan_id: PLAN-HCC-IMBRAVE150-001-V1 | version: 1 | generated: 2026-08-18T07:59:48.760213+00:00
Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.
Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.
This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.