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Yu et al. Hepatoma Res. 2025;11:29 | https://dx.doi.org/10.20517/2394-5079.2025.47 Page 3 of 12

within 1 week before immunotherapy. Multicolor flow cytometry was employed to perform quantitative
analysis of peripheral blood lymphocyte subsets. All operations were completed in the Laboratory
Department of Jiangsu Provincial Cancer Hospital. TACE was repeated only when imaging unequivocally
demonstrated residual or recurrent viable tumor. Inclusion criteria: (1) patients with clinically or
pathologically confirmed HCC according to the American Association for the Study of Liver Diseases
guidelines; (2) patients received more than one cycle of ICIs; (3) patients received TACE on demand. (4)
HCC at stage BCLC stage B (patients with diffuse, infiltrative, extensive HCC liver involvement) or C; (5)
informed consent has been obtained; (6) life expectancy ≥ 6 months; (7) patients had complete clinical data.
Exclusion criteria: (1) serious medical diseases (severe hypertension and diabetes, heart failure, thyroid
dysfunction, etc.) before immunotherapy; (2) unable to cooperate with the investigators; (3) medical
records could not be collected completely; (4) combined with two or more primary malignant tumors.

Treatment procedure
Enrolled patients received one of five intravenous ICIs: tislelizumab, pembrolizumab, camrelizumab,
sintilimab, or toripalimab. Tislelizumab, pembrolizumab, camrelizumab, and sintilimab were administered
at a fixed dose of 200 mg every 21 days, whereas toripalimab was given at a fixed dose of 240 mg on the
same schedule. TACE was repeated strictly on demand, prompted by radiologic evidence of viable tumor.
Laboratory profiles were monitored monthly, and contrast-enhanced MRI (magnetic resonance imaging)
or CT (computed tomography) was obtained every 1-3 months in all patients.

Outcomes and assessments
sirAEs were defined as severe immune dysregulation adverse events (grade ≥ 3) such as thyroid
dysfunction, immune-related pneumonitis, rash, and myocarditis that occurred during or after
immunotherapy. irAEs were evaluated by investigators without prior knowledge of the relevant
information using the “Common Terminology Criteria for Adverse Events 5.0” of the National Cancer
Institute to obtain data on the type and grade of irAEs.

Statistical analysis
SPSS (Statistical Package for the Social Sciences) 26.0 and R software were used to analyze all statistical data.
Analysis of variance, chi-square test and t-test were used to analyze the clinical data. A binary logistic
regression model was used to analyze the correlation between clinical risk factors and the occurrence of
sirAEs in HCC patients. According to the influencing factors obtained by multivariate logistic regression
(P < 0.05), the R software was used to construct a nomogram model. Receiver operating characteristic
(ROC) and calibration curves were used to verify the nomogram.

RESULTS
Patient characteristics
A total of 46 HCC patients who developed sirAEs between January 2020 and June 2024 were included in the
sirAEs group, and 84 HCC patients who did not develop sirAEs were included in the control group. There
were 22 patients with Child-Pugh = 5 in the sirAEs group and 57 patients with Child-Pugh = 5 in the
control group. The number of patients with Child-Pugh > 5 in the sirAEs group was significantly more than
that in the control group (P < 0.05). There were 13 patients with cirrhosis in the sirAEs group and 57
patients with cirrhosis in the control group. The incidence of liver cirrhosis was significantly higher in the
sirAEs group than that in the control group (P < 0.01). Neutrophil-to-Lymphocyte Ratio (NLR) in the
sirAEs group was 1.79 ± 1.16, and NLR in the control group was 3.42 ± 1.58. NLR was significantly elevated
in the control group relative to the sirAEs group (P < 0.05). The number of Regulatory T cells (Tregs) in the
sirAEs group and the control group was 6.07 ± 4.97 and 9.79 ± 5.24, respectively. The number of Tregs in
the control group was significantly higher than that in the sirAEs group (P < 0.05). The number of