Supplementary Material for: Fever Following Treatment with Atezolizumab Plus Bevacizumab Predicts Liver Injury in Patients with Unresectable Hepatocellular Carcinoma: A Prospective Observational Analysis

Introduction: Liver injury is a treatment-related adverse event (liver-TRAE), one of the most common complications of atezolizumab plus bevacizumab (Atez/Bev) therapy, when treating unresectable hepatocellular carcinoma (uHCC). Fever following immune checkpoint inhibitor (ICI) therapy may predict ICI-induced liver injury in various malignancy types. However, the association between fever and liver-TRAEs in patients with uHCC treated with Atez/Bev has not been investigated. We prospectively evaluated the relationship between the onset of liver-TRAEs and preceding fever and sought to identify circulating biomarkers that predict liver injury in patients with Atez/Bev-treated uHCC.
Methods: The primary outcome of this prospective, multicenter study was the association between liver-TRAEs (Grade ≥2) and the presence of ICI-induced fever before the onset of liver injury. We used a multiplex bead-based immunoassay to evaluate 40 circulating proteins in the serum before and at 1, 3, and 6 weeks after initial Atez/Bev treatment.
Results: Among 99 patients receiving Atez/Bev, Grade ≥2 liver-TRAEs occurred in 10 (10.1%) during the follow-up period (median, 14.7 months). The incidences of liver-TRAEs associated with fever before liver injury were 27.8% (n=5/18) and 6.2% (n=5/81) in the fever and non-fever groups, respectively. Multivariable analysis showed that the presence of fever was a significant risk factor for liver-TRAEs (odds ratio 7.57; 95% confidence interval, 1.83–33.89; P=0.006). Furthermore, the prognosis was worse in the liver-TRAE (Grade ≥2) group (P=0.065 for progression-free survival and P=0.074 for overall survival). Among patients with preceding fever, the liver-TRAE group had significantly lower CXCL-5 levels before treatment, higher IL-6 levels at 1 and 3 weeks, and lower CXCL-5, IFN-γ, and IL-10 levels at 6 weeks (P<0.05).
Conclusion: Fever during Atez/Bev treatment may predict liver-TRAEs, which leads to poor prognosis in patients with uHCC. Altered inflammatory cytokine and chemokine levels may help predict liver-TRAEs in patients with fever after Atez/Bev therapy.

引言：在不可切除肝细胞癌（unresectable hepatocellular carcinoma, 简称uHCC）的治疗中，肝损伤属于阿替利珠单抗联合贝伐珠单抗（atezolizumab plus bevacizumab, 简称Atez/Bev）疗法的治疗相关不良事件（肝源性治疗相关不良事件，liver-TRAE），同时也是该疗法最常见的并发症之一。免疫检查点抑制剂（immune checkpoint inhibitor, 简称ICI）治疗后出现的发热，在多种恶性肿瘤中可预测该类抑制剂诱导的肝损伤。然而，针对接受Atez/Bev治疗的uHCC患者，发热与肝源性治疗相关不良事件之间的关联尚未得到研究。本研究前瞻性评估了肝源性治疗相关不良事件的发生与此前发热的关联，并试图筛选可预测接受Atez/Bev治疗的uHCC患者肝损伤的循环生物标志物。

方法：本项前瞻性多中心研究的主要结局为≥2级肝源性治疗相关不良事件与肝损伤发生前出现ICI诱导性发热的关联。研究采用多重磁珠免疫测定法，对初始Atez/Bev治疗前以及治疗后1、3、6周的血清中40种循环蛋白进行检测分析。

结果：在99例接受Atez/Bev治疗的患者中，随访期（中位时长14.7个月）内有10例（10.1%）发生了≥2级肝源性治疗相关不良事件。发热组与非发热组中，肝损伤前伴随发热的肝源性治疗相关不良事件发生率分别为27.8%（5/18）与6.2%（5/81）。多变量分析显示，发热是肝源性治疗相关不良事件的独立危险因素（比值比7.57；95%置信区间1.83~33.89；P=0.006）。此外，≥2级肝源性治疗相关不良事件组患者的预后更差（无进展生存期P=0.065，总生存期P=0.074）。在既往出现发热的患者中，发生肝源性治疗相关不良事件的患者治疗前CXC趋化因子配体5（CXCL-5）水平显著更低，治疗后1、3周的白细胞介素6（IL-6）水平更高，而治疗后6周的CXCL-5、干扰素γ（IFN-γ）及白细胞介素10（IL-10）水平显著更低（P<0.05）。

结论：接受Atez/Bev治疗期间出现的发热可预测uHCC患者的肝源性治疗相关不良事件，而此类不良事件会导致患者预后不良。炎症细胞因子与趋化因子水平的异常变化，或可辅助预测接受Atez/Bev治疗后出现发热的患者的肝源性治疗相关不良事件。