Prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in hepatocellular carcinoma patients treated with atezolizumab plus bevacizumab: real-world data from Vietnam

Abstract Background Atezolizumab plus bevacizumab is the standard-of-care systemic regimen for advanced hepatocellular carcinoma (HCC). Accessible prognostic indicators are valuable in real-world practice, particularly in populations with a high burden of hepatitis B virus (HBV). Objective To evaluate the prognostic value of pretreatment neutrophil-to-lymphocyte ratio (NLR) and determine a pragmatic, clinically interpretable threshold for risk stratification. Materials and methods This retrospective, single-center study included 233 patients with advanced HCC treated with atezolizumab plus bevacizumab at the Vietnam National Cancer Hospital (February 2020 – April 2026; follow-up censored June 17, 2026). Candidate NLR thresholds were evaluated through Kaplan-Meier survival curves, multivariable Cox proportional hazards models, and internal validation techniques. Results Median patient age was 59 years; 91.4% were male, 72.5% had HBV etiology, and 31.3% met real-world trial-ineligibility criteria (IMbrave150-OUT). Median baseline NLR was 2.34 (IQR: 1.71–3.73). Continuous NLR was associated with overall survival (OS) and progression-free survival (PFS). Among candidate thresholds, NLR ≥ 3.6 provided optimal risk separation, significantly stratifying median OS (15.64 vs. 10.02 months; p < 0.001) and median PFS (4.34 vs. 3.25 months; p = 0.039). In the final multivariable Cox model (n = 210), NLR ≥ 3.6 remained an independent prognostic factor for both OS (adjusted HR 1.73; 95% CI, 1.13–2.66; p = 0.012) and PFS (adjusted HR 1.50; 95% CI, 1.05–2.14; p = 0.025). Conclusion Pretreatment NLR ≥ 3.6 serves as a simple, independent adjunctive biomarker for risk stratification in real-world patients with HCC receiving atezolizumab plus bevacizumab, including those ineligible for pivotal clinical trials. External validation in prospective cohorts is warranted.