Sorafenib in advanced hepatocellular carcinoma

Prognostic comparison between pulmonary metastasectomy and combination immunotherapy with targeted molecular therapies for advanced hepatocellular carcinoma with pulmonary metastasis: A propensity score matching analysis

Background and aims

Advanced hepatocellular carcinoma (HCC) with pulmonary metastasis (PM) has a poor prognosis, and optimal treatment strategies remain controversial. This study aimed to compare the long-term outcomes of patients with advanced HCC with PM who were treated with resection of pulmonary metastases versus those treated with targeted therapies combined with immunotherapy.

Methods

A retrospective analysis was conducted on the medical records of HCC patients with PM who underwent either pulmonary metastasectomy or immunotherapy combined with targeted therapies at the Eastern Hepatobiliary Surgery Hospital, Changhai Hospital of Shanghai, Fujian Provincial Hospital, and West China Hospital of Sichuan University from September 2013 to October 2022. One-to-one propensity score matching (PSM) was employed to control the influence of potential confounders, and the survival outcomes were compared.

Results

A total of 119 HCC patients with PM were included in this study. The overall survival (OS) of patients who underwent pulmonary metastasectomy was significantly longer than that of patients who received immunotherapy targeted combinations (OS: 1-year, 80.0% vs. 59.3%; 2-year, 31.7% vs. 20.3%; 3-year, 20.0% vs. 0; P < 0.001). After PSM, the long-term prognosis of the pulmonary metastasectomy group remained significantly better than that of the immunotherapy combination group (OS: 1-year, 87.0% vs. 69.6%; 2-year, 34.8% vs. 30.4%; 3-year, 21.7% vs. 0; P = 0.005). Multivariate analysis revealed that treatment allocation (hazard ratio (HR) = 2.177, 95% confidence interval (CI) = 1.068-4.439) and hepatic tumor T stage (HR = 2.342, 95% CI = 1.209-4.538) were independent risk factors for OS.

Conclusions

Pulmonary metastasectomy was associated with improved survival compared to immunotherapy combined with targeted therapies and may represent an optimal treatment option for highly selected HCC patients with resectable PM.

A Phase I Study of the Naturally Occurring Bioactive, Opioid Growth Factor, in Patients with Unresectable Hepatocellular Cancer

Hepatocellular cancer (HCC), one of the world's most deadly tumors, and its incidence in the US continues to rise. Surgical resection/transplantation offers the only hope for cure; however, many patients are not candidates and have limited therapeutic options. Opioid growth factor (OGF) is a naturally occurring bioactive endogenous pentapeptide that inhibits growth of human HCC cell lines in vitro by a receptor-mediated mechanism and inhibits progression of tumors in nude mice. Based on these preclinical studies, we conducted a phase I clinical trial with dose escalation (standard 3 + 3 protocol) of OGF to determine the maximum tolerated dose in HCC patients with concomitant liver disease (NCT00706576). Fifteen doses were administered to 14 patients with a maximum 300 µg/kg dose. No Grade 3 toxicities were encountered in the study group. This dose exceeds the maximum tolerated dose reached in our previous phase I pancreatic cancer trial. We conclude that OGF can be safely administered to patients with HCC and concomitant liver disease without significant toxicities up to a dose of 300 µg/kg. The result of this trial provides data on toxicity and the pharmacokinetics of OGF in patients with HCC and liver disease and lays the groundwork for additional studies.

An open-label study to determine the maximum tolerated dose of oral ESK-440 administered as a single agent in patients with advanced or metastatic solid tumors

PURPOSE

Anaplastic lymphoma kinase (ALK) dysregulation is implicated in numerous cancers. Tyrosine kinase inhibitors (TKIs) targeting ALK have improved disease outcomes, but resistance mechanisms are common. This first-in-human trial evaluates ESK-440, a dual inhibitor of ALK and focal adhesion kinase, as a novel strategy for cancers with resistance to ALK-targeting TKIs.

METHODS

This phase 1, open-label, dose-finding study evaluated the maximum tolerated dose (MTD), safety, efficacy, and pharmacokinetics of ESK-440 in participants with advanced or metastatic solid tumors (ClinicalTrials.gov: NCT01922752). A 3 + 3 dose-escalation design, with daily doses ranging from 25 to 700 mg/day of ESK-440 for each 28-day treatment cycle (6 to 8 cycles) was utilized to identify the MTD. A phase 1b was planned to further evaluate ESK-440 safety and antitumor activity at the MTD but was not performed due to sponsor decision.

RESULTS

32 participants were enrolled and 24 (75 %) completed cycle 1 of treatment. Three dose-limiting toxicities, all grade 3 nausea, were reported (n = 1, 500 mg; n = 2, 700 mg). The MTD was determined to be 500 mg daily. The most frequent adverse events (AEs) were fatigue and nausea (53 % each) and vomiting (38 %). Seven participants (22 %) withdrew from treatment due to AEs and 4 deaths occurred, none related to ESK-440. No participant had a complete or partial response; the best overall response was stable disease in 7 participants.

CONCLUSIONS

ESK-440 was safe and tolerable with a maximum tolerated dose of 500mg daily; however, the study was terminated early based on sponsor decision.

Correlation Between Treatment-Related Adverse Events and Efficacy of Camrelizumab in Combination With Apatinib in Patients With Unresectable Hepatocellular Carcinoma

BACKGROUND

The relationship between treatment-related adverse events (TRAEs) and efficacy in patients receiving immune checkpoint inhibitors (ICIs) combined with anti-angiogenic therapy remains unclear. This study aims to investigate the potential correlation between TRAEs and efficacy in patients with unresectable hepatocellular carcinoma (uHCC) treated with the combination of camrelizumab and apatinib.

METHODS

We conducted an analysis of efficacy and safety data obtained from 189 patients with uHCC enrolled in a phase II trial. All patients received intravenous camrelizumab 200 mg every 2 weeks and oral apatinib 250 mg once daily in 4-week cycles. Efficacy was evaluated based on objective response rate (ORR), disease control rate (DCR), progression-free survival (PFS), and overall survival (OS). We described the profiles of TRAEs and analyzed the correlation between TRAEs and treatment efficacy. To mitigate the impact of immortal time bias, landmark analysis and time-dependent Cox regression analysis were employed to assess the correlation between immune-related adverse events (irAEs) and survival outcomes.

RESULTS

As of March 10, 2021, irAEs of any grade were reported in 88 (46.6%) patients, with 17 (9.0%) patients experiencing grade 3-4 irAEs. The median onset time for any grade irAEs was 17.4 weeks. Apatinib-related adverse events (AEs) of any grade were reported in 188 (99.5%) patients. Among them, 139 (73.5%) patients experienced any grade of apatinib-related hypertension, while 65 (34.4%) patients had grade 3-4 hypertension. Patients who experienced irAEs exhibited significantly higher ORR and DCR, but the onset of irAEs occurred later than the time of PR or CR in 75.0% (30/40) of patients. Furthermore, in the landmark analysis and time-dependent Cox regression analysis, no significant differences in survival outcomes were observed between patients with irAEs and those without. Notably, patients with apatinib-related hypertension demonstrated better ORR (38.1% vs. 18.0%, p = 0.009) and DCR (84.2% vs. 60.0%, p < 0.001), as well as longer PFS (6.5 vs. 3.7 months, p = 0.001) and OS (23.0 vs. 15.1 months, p = 0.03).

CONCLUSIONS

In this study, the occurrence of irAEs did not predict the efficacy of camrelizumab in combination with apatinib, likely due to the decreased incidence and delayed occurrence. On the other hand, apatinib-related hypertension was associated with improved treatment efficacy.

Human-correlated genetic models identify precision therapy for liver cancer

Hepatocellular carcinoma (HCC), the most common form of primary liver cancer, is a leading cause of cancer-related mortality worldwide1,2. HCC occurs typically from a background of chronic liver disease, caused by a spectrum of predisposing conditions. Tumour development is driven by the expansion of clones that accumulate progressive driver mutations3, with hepatocytes the most likely cell of origin2. However, the landscape of driver mutations in HCC is broadly independent of the underlying aetiologies4. Despite an increasing range of systemic treatment options for advanced HCC, outcomes remain heterogeneous and typically poor. Emerging data suggest that drug efficacies depend on disease aetiology and genetic alterations5,6. Exploring subtypes in preclinical models with human relevance will therefore be essential to advance precision medicine in HCC7. Here we generated a suite of genetically driven immunocompetent in vivo and matched in vitro HCC models. Our models represent multiple features of human HCC, including clonal origin, histopathological appearance and metastasis. We integrated transcriptomic data from the mouse models with human HCC data and identified four common human-mouse subtype clusters. The subtype clusters had distinct transcriptomic characteristics that aligned with the human histopathology. In a proof-of-principle analysis, we verified response to standard-of-care treatment and used a linked in vitro-in vivo pipeline to identify a promising therapeutic candidate, cladribine, that has not previously been linked to HCC treatment. Cladribine acts in a highly effective subtype-specific manner in combination with standard-of-care therapy.

Outcomes of Stereotactic Body Radiotherapy Compared with Surgical Resection in Patients with Hepatocellular Carcinoma and Macrovascular Invasion: A Propensity Score-Matched Analysis

INTRODUCTION

Patients with advanced hepatocellular carcinoma (HCC) and macrovascular invasion (MVI) are recommended to receive systemic therapy according to guidelines. Stereotactic body radiotherapy (SBRT) and surgery are increasingly used in this patient population. This study compares outcomes from these local treatments.

METHODS

Patients diagnosed with HCC with MVI and treated with surgery or SBRT between 1999 and 2022 were included. Propensity score matching minimized bias from confounders. Overall survival (OS) was analyzed using the Kaplan-Meier method,. and local, regional, and distant recurrences were assessed via competing risk methods. Univariable and multivariable analyses adjusted by the Lasso method evaluated OS predictors.

RESULTS

Among 175 patients, 38 underwent surgery and 137 received SBRT. The median age was 61 years, tumor volume was 158.6 cc, and α-fetoprotein level was 197 IU/mL. Most surgical patients had major resection (74%) via an open approach (97%). The median biologically effective dose (BED) for SBRT was 53.7 Gy. After matching, 35 patients per group had a median OS of 16 months. Local failure was higher in the SBRT group (20%) than in the surgery group (12%) at 1 year (p = 0.028). Distant failure was more frequent in surgery (54%) compared with SBRT (17%) [p = 0.003]. Excluding SBRT patients receiving adjuvant systemic therapy did not change the results. In-hospital mortality was 9% post-surgery and 14% experienced post-SBRT liver impairment.

CONCLUSION

Both surgery and SBRT offer good long-term OS and control. Surgery provides better local control, while SBRT had lower distant relapse. While SBRT has acceptable toxicity, surgery carries a significant mortality risk.

Surgical treatment for hepatocellular carcinoma in era of multidisciplinary strategies

Hepatocellular carcinoma (HCC) remains a significant global health challenge, with over 800,000 new cases diagnosed annually. This comprehensive review examines current surgical approaches and emerging multidisciplinary strategies in HCC treatment. While traditional surgical criteria, such as the Barcelona Clinic Liver Cancer (BCLC) staging system, have been relatively conservative, recent evidence from high-volume Asian centers supports more aggressive surgical approaches in carefully selected patients. The review discusses the evolution of selection criteria, including the new "Borderline Resectable HCC" classification system, which provides more explicit guidance for surgical decision-making. Technical innovations have significantly enhanced surgical precision, including three-dimensional simulation, intraoperative navigation systems, and the advancement of minimally invasive approaches. The review evaluates the ongoing debate between anatomical versus non-anatomical resection and examines the emerging role of robotic surgery. In liver transplantation, expanded criteria beyond the Milan criteria show promising outcomes, while the integration of novel biomarkers and imaging techniques improves patient selection. The role of preoperative and adjuvant therapies is increasingly important, with recent trials demonstrating the potential of immune checkpoint inhibitors combined with anti-VEGF agents in both settings. Despite these advances, postoperative recurrence remains a significant challenge. The review concludes that successful HCC treatment requires a personalized approach, integrating surgical expertise with emerging technologies and systemic therapies while considering individual patient factors and regional variations in practice patterns.

Advancements in second-line treatment research for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors, characterized by high incidence and mortality rates. Due to its insidious onset, most patients are diagnosed at an advanced stage, often missing the opportunity for surgical resection. Consequently, systemic treatments play a pivotal role. In recent years, an increasing number of drugs have been approved for first-line systemic treatment of HCC. However, their efficacy is limited, and some patients develop drug resistance after a period of treatment. For such patients, there is currently a lack of standard second-line systemic treatment options. This review summarizes the latest advancements in second-line systemic treatment research for HCC patients who have developed resistance to various first-line systemic treatments, aiming to provide more rational and personalized second-line treatment strategies.

Phase II study with sorafenib plus radiotherapy for advanced HCC with portal and/or hepatic vein tumor thrombosis

BACKGROUND & AIMS

Portal and hepatic vein tumor thrombosis is associated with inferior outcomes in patients with hepatocellular carcinoma (HCC), and systemic treatment alone is often insufficient. This phase II trial evaluated the efficacy and safety of combining sorafenib with radiotherapy in advanced HCC with thrombosis.

METHODS

Registered at ClinicalTrials.gov (NCT03535259), this phase II single-arm prospective trial targeted patients with HCC with portal or hepatic vein tumor thrombosis, liver minus gross tumor volume >700 ml, and Eastern Cooperative Oncology Group Performance Status scores of 0 or 1. Participants underwent 40-66 Gy radiotherapy for the hepatic primary tumor and vein tumor thrombosis, with concurrent oral sorafenib (400 mg twice daily) until disease progression or unacceptable adverse events. The primary endpoint was median overall survival (mOS) and the secondary endpoints included overall response rate (ORR) per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 and Modified Response Evaluation Criteria in Solid Tumors (mRECIST), median progression-free survival (mPFS), time to tumor progression (TTP), tumor thrombosis control, and grade ≥3 adverse events.

RESULTS

Between May 2018 and January 2020, 86 patients were enrolled with a median radiotherapy dose of 54 Gy (40-65 Gy). At a median follow-up of 17.2 months, mOS, mPFS, and TTP stood at 16.5, 6.1, and 6.8 months, respectively. ORR reached 47.7% and 52.3% per RECIST and mRECIST, respectively. For the tumor thrombosis, 2-year control rates per mRECIST were 93.1%. No grade 5 adverse events were noted, whereas thrombocytopenia (22.1%) and leukopenia (14.0%) were the main grade 3 adverse events.

CONCLUSIONS

Concurrent sorafenib and radiotherapy is an effective and well-tolerated treatment for patients with HCC with portal or hepatic vein tumor thrombosis.

IMPACT AND IMPLICATIONS

Treatment options for patients with hepatocellular carcinoma (HCC) and vascular tumor thrombus are limited. The efficacy and safety of concurrent sorafenib and radiation for HCC with portal or hepatic vein tumor thrombosis has not been elucidated. This phase II trial shows that concurrent sorafenib and radiotherapy is effective and well-tolerated in the treatment of advanced HCC with portal vein or hepatic vein tumor thrombosis.

CLINICAL TRIALS REGISTRATION

This study is registered at ClinicalTrials.gov (NCT03535259).

Metabolic reprogramming in hepatocellular carcinoma: mechanisms and therapeutic implications

Hepatocellular carcinoma features extensive metabolic reprogramming. This includes alterations in major biochemical pathways such as glycolysis, the pentose phosphate pathway, amino acid metabolism and fatty acid metabolism. Moreover, there is a complex interplay among these altered pathways, particularly involving acetyl-CoA (coenzyme-A) metabolism and redox homeostasis, which in turn influences reprogramming of other metabolic pathways. Understanding these metabolic changes and their interactions with cellular signaling pathways offers potential strategies for the targeted treatment of hepatocellular carcinoma and improved patient outcomes. This review explores the specific metabolic alterations observed in hepatocellular carcinoma and highlights their roles in the progression of the disease.

Quantitative evaluation of the efficacy and safety of first-line systemic therapies for advanced hepatocellular carcinoma

OBJECTIVES

This study aimed to quantitatively evaluate the efficacy and safety of first-line systemic therapies for treating advanced hepatocellular carcinoma (aHCC).

METHODS

The study included clinical trials of first-line systemic therapies for aHCC since the approval of sorafenib in 2007. Hazard function models were used to describe changes in overall survival (OS) and progression-free survival (PFS) over time. Monte Carlo simulation was used to compare OS and PFS for different treatments, including sorafenib, antiangiogenic therapies (AATs) (except sorafenib), immune checkpoint inhibitor (ICI) monotherapy, AAT + targeted therapy, AAT + chemotherapy, AAT + ICIs, and ICIs + ICIs. Furthermore, the objective response rate (ORR) and incidence of grade ≥ 3 adverse events were analyzed.

RESULTS

Fifty studies comprising 12,918 participants were included. AAT + ICIs demonstrated a significant benefit in median OS (mOS), median PFS (mPFS), and ORR (20.5 [95% CI 17.5-24] months, 7.5 [95% CI 6.5-8.8] months, and 24% [95% CI 17%-30%], respectively). ICIs + ICIs and ICI monotherapy ranked second and third, respectively with an mOS of 20 (95% CI 18.5-21.5) months and 14.5 (95% CI 13.5-16) months, respectively. The OS, PFS, and ORR of patients treated with AAT, AAT + targeted therapy, and AAT + chemotherapy were similar to those of patients treated with sorafenib. A higher proportion of patients with Barcelona Clinic Liver Cancer (BCLC) stage C had a shorter OS. OS was associated with publication year, and PFS was associated with the proportion of patients with BCLC stage C. The incidence of grade ≥ 3 adverse events in the ICIs and ICIs + ICIs treatment groups was low.

CONCLUSIONS

The study results provide valuable information from which to base rational clinical drug use and serves as a reliable external control for evaluating new treatments for aHCC.

Impact of immunotherapy on the care patterns and outcomes of patients with advanced hepatocellular carcinoma

BACKGROUND

Modern immunotherapy with checkpoint inhibitors revolutionized cancer treatment and outcomes. This study aims to demonstrate how immunotherapy has impacted the national landscape of systemic treatment and palliative care in advanced hepatocellular carcinoma (HCC).

METHODS

Retrospective cohort selecting patients from the U.S.-based National Cancer Database (NCDB) with clinical stages T3b/T4 and stage IV HCC from 2010 to 2021. We performed a multivariable analysis using the Cox proportional hazard for overall survival (OS) comparisons and a logistic regression model to study immunotherapy use.

RESULTS

Immunotherapy use increased from 0.27 % in 2010 to 33.80 % in 2021. The median OS survival (in months) was 2 for untreated patients, 7.20 for chemotherapy, and 7.46 for immunotherapy. There was a better OS with immunotherapy (HR 0.59, 95 % CI 0.56-0.62). Systemic therapy for palliation increased from 14.41 % in 2010 to 25.32 % in 2021. Compared to surgical palliation, radiation (HR 0.61, 95 % CI 0.52-0.71) and systemic palliative (HR 0.59, 95 % CI 0.51-0.69) therapies improved OS.

CONCLUSION

From 2010 to 2021, there was a significant increase in the use of immunotherapy, parallel to a large shift toward systemic therapy use for palliative care in patients with advanced HCC. Immunotherapy was associated with a significant OS benefit in the palliative setting.

Precision models in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents a global health challenge, and ranks among one of the most prevalent and deadliest cancers worldwide. Therapeutic advances have expanded the treatment armamentarium for patients with advanced HCC, but obstacles remain. Precision oncology, which aims to match specific therapies to patients who have tumours with particular features, holds great promise. However, its implementation has been hindered by the existence of numerous 'HCC influencers' that contribute to the high inter-patient heterogeneity. HCC influencers include tumour-related characteristics, such as genetic alterations, immune infiltration, stromal composition and aetiology, and patient-specific factors, such as sex, age, germline variants and the microbiome. This Review delves into the intricate world of HCC, describing the most innovative model systems that can be harnessed to identify precision and/or personalized therapies. We provide examples of how different models have been used to nominate candidate biomarkers, their limitations and strategies to optimize such models. We also highlight the importance of reproducing distinct HCC influencers in a flexible and modular way, with the aim of dissecting their relative contribution to therapy response. Next-generation HCC models will pave the way for faster discovery of precision therapies for patients with advanced HCC.

Exploring the Role of Metabolic Hyperferritinaemia (MHF) in Steatotic Liver Disease (SLD) and Hepatocellular Carcinoma (HCC)

The increasing prevalence of the spectrum of Steatotic Liver Disease (SLD), including Metabolic-Associated Steatotic Liver Disease (MASLD), Metabolic-Associated Steatohepatitis (MASH), and progression to Cirrhosis and Hepatocellular Carcinoma (HCC) has led to intense research in disease pathophysiology, with many studies focusing on the role of iron. Iron overload, which is often observed in patients with SLD as a part of metabolic hyperferritinaemia (MHF), particularly in the reticuloendothelial system (RES), can exacerbate steatosis. This imbalance in iron distribution, coupled with a high-fat diet, can further promote the progression of SLD by means of oxidative stress triggering inflammation and activating hepatic stellate cells (HSCs), therefore leading to fibrosis and progression of simple steatosis to the more severe MASH. The influence of iron overload in disease progression has also been shown by the complex role of ferroptosis, a type of cell death driven by iron-dependent lipid peroxidation. Ferroptosis depletes the liver's antioxidant capacity, further contributing to the development of MASH, while its role in MASH-related HCC is potentially linked to alternations in the tumour microenvironment, as well as ferroptosis resistance. The iron-rich steatotic hepatic environment becomes prone to hepatocarcinogenesis by activation of several pro-carcinogenic mechanisms including epithelial-to-mesenchymal transition and deactivation of DNA damage repair. Biochemical markers of iron overload and deranged metabolism have been linked to all stages of SLD and its associated HCC in multiple patient cohorts of diverse genetic backgrounds, enhancing our daily clinical understanding of this interaction. Further understanding could lead to enhanced therapies for SLD management and prevention.

Systemic Treatment for Unresectable Hepatocellular Carcinoma: A Surgeon's Perspective

In recent years, the standard treatment for hepatocellular carcinoma (HCC) has changed dramatically due to the emergence of potent systemic treatment options. These advanced therapies have led to increased survival benefits for patients with advanced or intermediate-stage HCC. Advancements in HCC treatments also offer the possibility of conversion therapy for initially unresectable HCC. However, the treatment of HCC is becoming increasingly complex, due to the expanding availability of systemic therapies, their use in combination with locoregional therapies, and their perioperative applications. Patient characteristics such as liver function, esophageal and gastric variceal status, and treatment goal (downstaging resection or long-term maintenance treatment), are the most critical factors when selecting a systemic treatment strategy. Consequently, the necessity to tailor a personalized and comprehensive treatment strategy for individual patients is growing. This review briefly summarizes the current systemic treatment regimens for HCC from a surgeon's perspective. It is based on results from clinical studies as well as personal experience and introduces the concept of a patient-centered, treatment goals-driven, individualized systemic treatment strategy for managing HCC.

Enhanced efficacy of immune checkpoint inhibitors combined locoregional therapy and tyrosine kinase inhibitors in the treatment of unresectable hepatocellular carcinoma: A single - center retrospective study

Background

Unresectable hepatocellular carcinoma (HCC) presents significant treatment challenges. While locoregional therapies (LT) and tyrosine kinase inhibitors (TKI) offer some benefits, prognosis remains poor. Immune checkpoint inhibitors (ICI) have shown promise in other oncological settings, suggesting potential benefits in HCC treatment regimens.

Methods

This retrospective study analyzed 232 patients diagnosed with unresectable HCC at West China Hospital from January 2019 to December 2023. Patients were categorized into two treatment groups: LT+TKI and LT+TKI+ICI. All patients underwent standardized locoregional treatments and first-line TKIs, with the latter group also receiving ICIs. The primary endpoints measured were overall survival (OS) and progression-free survival (PFS). Survival analysis utilized Kaplan-Meier estimates and Cox regression models.

Results

The LT+TKI+ICI group demonstrated significantly improved survival outcomes compared to the LT+TKI group. Median OS was 28 ± 3.9 months in the LT+TKI+ICI group versus 21 ± 3.0 months in the LT+TKI group, with corresponding 6-, 12-, and 24-month OS rates of 96.8%, 79.3%, and 59.4% versus 85.8%, 71.5%, and 44.1%, respectively (HR, 0.64; 95% CI, 0.449-0.913; P = 0.014). Median PFS also favored the LT+TKI+ICI group (11 ± 1.1 months vs. 7 ± 0.76 months; HR, 0.60; 95% CI, 0.452-0.805; P<0.001). Multivariable analysis identified LT+TKI, vascular invasion, and metastasis as independent risk factors for poorer survival outcomes.

Conclusions

Adding ICI to LT and TKI significantly extends both OS and PFS in patients with unresectable HCC. These findings suggest that integrating ICI into treatment protocols could be beneficial in managing unresectable HCC, particularly for patients with vascular invasion.

Advances in Immunotherapy in Hepatocellular Carcinoma

Over the past several years, the therapeutic landscape for patients with advanced, unresectable, or metastatic hepatocellular carcinoma has been transformed by the incorporation of checkpoint inhibitor immunotherapy into the treatment paradigm. Frontline systemic treatment options have expanded beyond anti-angiogenic tyrosine kinase inhibitors, such as sorafenib, to a combination of immunotherapy approaches, including atezolizumab plus bevacizumab and durvalumab plus tremelimumab, both of which have demonstrated superior response and survival to sorafenib. Additionally, combination treatments with checkpoint inhibitors and tyrosine kinase inhibitors have been investigated with variable success. In this review, we discuss these advances in systemic treatment with immunotherapy, with a focus on understanding both the underlying biology and mechanism of these strategies and their efficacy outcomes in clinical trials. We also review challenges in identifying predictive biomarkers of treatments and discuss future directions with novel immunotherapy targets.

CRAFITY score and nomogram predict the clinical efficacy of lenvatinib combined with immune checkpoint inhibitors in hepatocellular carcinoma

BACKGROUND

The CRAFITY score is mainly utilized for hepatocellular carcinoma (HCC) patients receiving atezolizumab and bevacizumab, with little investigation in its predictive capacity for alternative regimens, such as lenvatinib and programmed cell death protein 1 (PD-1) inhibitors, which are widely utilized in Chinese clinical practice.

AIM

To look at the predictive significance of the CRAFITY score in HCC patients taking lenvatinib and PD-1 inhibitors.

METHODS

The retrospective investigation consisted of 192 patients with incurable HCC who received lenvatinib and PD-1 inhibitors between January 2018 and January 2022. Patients were stratified according to CRAFITY score (based on baseline alpha-fetoprotein and C-reactive protein levels) into CRAFITY-low, CRAFITY-intermediate, and CRAFITY-high groups. Overall survival (OS) and progression-free survival (PFS) were assessed using Kaplan-Meier analysis, and independent prognostic factors were identified through Cox regression analysis. Nomograms were created to forecast survival for a year.

RESULTS

The median PFS and OS were the longest for patients in the CRAFITY-low group, followed by those in the CRAFITY-intermediate and CRAFITY-high groups (median PFS: 8.4 months, 6.0 months, and 3.1 months, P < 0.0001; median OS: 33.4 months, 19.2 months, and 6.6 months, P < 0.0001). Both the objective response rate (5%, 19.6%, and 22%, P = 0.0669) and the disease control rate (50%, 76.5%, and 80%, P = 0.0023) were considerably lower in the CRAFITY-high group. The findings from the multivariate analysis showed that a nomogram which included the tumor number, prior transarterial chemoembolization history, and CRAFITY score predicted 12-month survival with an area under the curve of 0.788 (95% confidence interval: 0.718-0.859), which was in good agreement with actual data.

CONCLUSION

The CRAFITY score is a valuable predictor of survival and treatment outcomes in patients receiving lenvatinib and PD-1 inhibitors.

Machine learning and multi-omics characterization of SLC2A1 as a prognostic factor in hepatocellular carcinoma: SLC2A1 is a prognostic factor in HCC

Hepatocellular carcinoma (HCC) is characterized by high incidence, significant mortality, and marked heterogeneity, making accurate molecular subtyping essential for effective treatment. Using multi-omics data from HCC patients, we applied diverse clustering algorithms to identify three HCC subtypes (HSs) with distinct prognostic characteristics. Among these, HS1 emerged as an immune-compromised subtype associated with the poorest prognosis. Additionally, we developed a novel, robust, and highly accurate machine learning-guided prognostic signature (MLPS) by integrating multiple machine learning algorithms and their combinations. Our study also identified SLC2A1, the core gene of MLPS, as being highly expressed during advanced stages of tumor progression. Knockdown experiments demonstrated that reducing SLC2A1 expression significantly suppressed the malignant behavior of HCC cells. Furthermore, SLC2A1 expression was linked to responsiveness to dasatinib and vincristine, suggesting potential therapeutic relevance. MLPS and SLC2A1 offer promising tools for individualized prognosis prediction and targeted therapy in HCC, providing new opportunities to improve patient outcomes.

Therapy Combining Sorafenib and Natural Killer Cells for Hepatocellular Carcinoma: Insights from Magnetic Resonance Imaging and Histological Analyses

Background/Objectives: Hepatocellular carcinoma (HCC) remains a significant global health issue due to its high mortality rate and resistance to standard treatments. Sorafenib, the first-line systemic therapy for unresectable HCC, shows limited effectiveness due to resistance and severe side effects. Recent studies suggest that combining sorafenib with immunotherapy, particularly natural killer (NK) cells, may improve treatment outcomes. Methods: This study examined the effectiveness of sorafenib combined with NK cells pretreated with interleukin-12 (IL-12) and interleukin-18 (IL-18) in a rat HCC model. Tumor progression and treatment outcomes were assessed using MRI and histological analysis. Results: The results show that combination therapy significantly reduced tumor growth, increased tumor cell density, and inhibited angiogenesis and fibrosis in the tumor microenvironment. The sorafenib- and IL-12/IL-18-pretreated NK cell combination enhanced tumor inhibition by overcoming drug resistance and modulating the immune response. Conclusions: This study suggests that this combination therapy could be a promising strategy for treating HCC, offering both direct antitumor effects and modification of the tumor microenvironment for better clinical outcomes.

Comprehensive Analysis of the Role of Heat Shock Proteins in the Immune Microenvironment and Clinical Significance of Hepatocellular Carcinoma

Purpose

Hepatocellular carcinoma (HCC) is a prevalent malignancy that not only imposes a substantial financial burden but also significantly impacts the quality of life and overall survival of affected individuals. Heat shock proteins (HSPs) are a protein class with significant involvement in safeguarding and restoring cellular integrity. They help restore proper protein structure by binding to and refolding denatured proteins. However, the specific role of HSPs in HCC requires further investigation.

Methods

We analyzed the genomic characteristics of HSPs in liver cancer in the TCGA and ICGC databases, and functional enriched analysis of HSPs. Construction of an HSPs-Related Prognostic Model for patients with hepatocellular carcinoma. HSP-related risk score (HRRS) was identified as an independent prognostic factor in patients with hepatocellular carcinoma, and the clinical pathological characteristics and immune microenvironment of high-risk and low-risk groups were compared. Further, we studied HRRS-based liver cancer treatment strategies and confirmed the protein expression of HSPD1 and DNAJC5 in normal liver tissues and hepatocellular carcinoma tissues by collecting human hepatocellular carcinoma tissues.

Results

We observed elevated expression levels of most HSPs across HCC tissues. In addition, 14 hSPs were found to be related to prognostic significance among HCC patients and utilized to develop HRRS prognostic model for prognosis prediction and risk stratification. The prognostic and immunotherapeutic response predictive value of HRRS was validated utilizing data from TCGA and GEO cohorts. Moreover, we created a nomogram to assess HRRS clinical utility and verified its efficiency through various methods. Through IHC was found that HSPD1 and DNAJC5 were significantly overexpressed in hepatocellular carcinoma tissues.

Conclusion

Our results lead us to conclude that HCC's development and progression are intimately associated with HSPs, and the HRRS model represents a potentially robust prognostic model that could assist in clinical decision-making regarding chemotherapy and immunotherapy for HCC patients. Moreover, HSPD1 and DNAJC5 have the potential to serve as therapeutic targets for HCC.

Hepatic artery infusion chemotherapy: A resurgence

In this manuscript, we comment on the article by Zhou et al, who assessed the efficacy of hepatic arterial infusion chemotherapy (HAIC) and its combination strategies for advanced hepatocellular carcinoma (HCC) using network meta-analysis methodology. We focus specifically on the potential advantages and role of HAIC in the treatment algorithm for advanced HCC. However, there remains numerous knowledge gaps before the role of HAIC can be established. There is significant heterogeneity of HAIC regimes with difficult interpretation of the clinical outcomes. Additionally, there is a lack of direct comparative data between HAIC, systemic chemotherapy, novel immunotherapies and targeted therapies. The underlying biochemical mechanisms that might explain the efficacy of HAIC and its effect on the HCC microenvironment requires further research. In the developing era of nanotechnology and targeted drug delivery systems, there is potential for integration of HAIC with novel technologies to effectively treat advanced HCC whilst minimising systemic complications.

Bidirectional regulation of the cyclic guanosine monophosphate-adenosine monophosphate synthase-stimulator of interferon gene pathway and its impact on hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) ranks as the fourth leading cause of cancer-related deaths in China, and the treatment options are limited. The cyclic guanosine monophosphate-adenosine monophosphate synthase (cGAS) activates the stimulator of interferon gene (STING) signaling pathway as a crucial immune response pathway in the cytoplasm, which detects cytoplasmic DNA to regulate innate and adaptive immune responses. As a potential therapeutic target, cGAS-STING pathway markedly inhibits tumor cell proliferation and metastasis, with its activation being particularly relevant in HCC. However, prolonged pathway activation may lead to an immunosuppressive tumor microenvironment, which fostering the invasion or metastasis of liver tumor cells.

AIM

To investigate the dual-regulation mechanism of cGAS-STING in HCC.

METHODS

This review was conducted according to the PRISMA guidelines. The study conducted a comprehensive search for articles related to HCC on PubMed and Web of Science databases. Through rigorous screening and meticulous analysis of the retrieved literature, the research aimed to summarize and elucidate the impact of the cGAS-STING pathway on HCC tumors.

RESULTS

All authors collaboratively selected studies for inclusion, extracted data, and the initial search of online databases yielded 1445 studies. After removing duplicates, the remaining 964 records were screened. Ultimately, 55 articles met the inclusion criteria and were included in this review.

CONCLUSION

Acute inflammation can have a few inhibitory effects on cancer, while chronic inflammation generally promotes its progression. Extended cGAS-STING pathway activation will result in a suppressive tumor microenvironment.

Exploring the potential of diosgenin as a promising antitumor agent through comprehensive spectroscopic characterization, solvent-solute interactions, topological properties, Hirshfeld surface, and molecular docking interactions with 2NZT and 2I1V proteins

This study characterizes the steroidal saponin diosgenin by theoretical and experimental spectroscopic techniques. Theoretical simulations were performed using the DFT/B3LYP/6-311++G(d,p) basis set to simulate spectroscopic, structural and other properties. Optimized geometries from simulations and experiments showed strong agreement, with R2 value of 0.99846 for bond lengths and 0.88092 for bond angles. Vibrational spectra revealed distinctive peaks for the methyl, methylene, and methine groups in diosgenin. Solvent-solute interactions on the Frontier Molecular Orbitals (FMO), Molecular Electrostatic Potential (MEP) surfaces, and electronic spectra were analyzed, revealing insights into diosgenin's behavior in different environments. The FMO energy gap shows that polar solvents like acetone, ethanol, and water have wider band gaps (6.22-6.23 eV) than non-polar solvents like benzene, chloroform, and toluene (6.17-6.20 eV), indicating stronger interactions with polar groups, enhanced stability, and reduced reactivity. NBO analysis shows substantial stabilization energy (14.71 kJ/mol) when electrons from oxygen's (O1) lone pair are donated to the anti-bonding orbital of O2C15 through the transition of LP (2) → σ*. The carbon (C15) situated between oxygen (O1) and (O2) exhibits increased electronegativity (-1.65605 e), confirming the electronegativity of the oxygen atoms. Hirshfeld surfaces shows that the crystal structure is mainly influenced by H…H (90.7 %) interaction. Topological analyses revealed molecular interactions and chemical bonding within diosgenin, highlighting its diverse chemical functionalities. Furthermore, molecular docking and ADME predictions underscores diosgenin's potential biological activity against human hexokinase (-8.09 kcal/mol) and phosphofructokinase (-8.35 kcal/mol), suggesting its efficacy as an antitumor drug.

Efficacy of sorafenib combined with transarterial chemoembolization in the treatment of advanced hepatocellular carcinoma: A meta-analysis

BACKGROUND

The combination of sorafenib with transarterial chemoembolization (TACE) is being investigated for its potential to improve outcomes in advanced hepatocellular carcinoma (HCC).

AIM

To evaluate the efficacy of this combined treatment strategy in enhancing overall survival (OS) and progression-free survival (PFS) compared to monotherapies.

METHODS

A systematic review was conducted following the PRISMA guidelines. A comprehensive search was performed across PubMed, EMBASE, Web of Science, and the Cochrane Library up to May 8, 2024. Studies were included if they compared sorafenib plus TACE to sorafenib alone or TACE alone in adults with advanced HCC. Primary outcomes were OS, PFS, response rates, and safety profiles. Data extraction and quality assessment were independently performed by two reviewers. Heterogeneity was assessed using the I² statistic, and a random-effects model was applied for pooling data. Sensitivity analysis and publication bias assessment were also conducted.

RESULTS

A total of twelve studies involving 1174 patients met the inclusion criteria. Significant heterogeneity was observed for both OS (I² = 72.6%, P < 0.001) and PFS (I² = 83.7%, P < 0.001). The combined treatment of sorafenib with TACE significantly improved OS [hazard ratio (HR) = 0.60, 95% confidence interval (CI): 0.44-0.76] and PFS (HR = 0.54, 95%CI: 0.38-0.69). Sensitivity analysis confirmed the robustness of these findings. Funnel plots and Egger's test indicated no significant publication bias.

CONCLUSION

Sorafenib combined with TACE significantly enhances both OS and PFS in patients with advanced HCC compared to monotherapy. This combination therapy represents a promising approach to improving clinical outcomes in advanced liver cancer.

Structure-Guided Optimization and Preclinical Evaluation of 6-O-Benzylguanine-Based Pin1 Inhibitor for Hepatocellular Carcinoma Treatment

Hepatocellular carcinoma (HCC) is a major cause of cancer-related deaths globally, and the need for effective systemic therapies for HCC is urgent. Our previous work reveals that Pin1 is a potential anti-HCC target, which regulates miRNA biogenesis and identifies API-1 as a novel Pin1 inhibitor to suppresses HCC. However, a great demand in HCC therapy as well as the limited chemical stability and pharmacokinetic feature of API-1 motivated us to find improved Pin1 inhibitors. Herein, we designed and synthesized diverse 6-O-benzylguanine derivatives and discovered API-32 as a novel Pin1 inhibitor with better stability and pharmacokinetic property over API-1. API-32 directly interacted with the Pin1 PPIase domain to inhibit Pin1 activity. API-32 significantly suppressed the cell proliferation and migration of HCC cells by blocking Pin1's downstream signal. Moreover, API-32 exhibited an enhanced inhibitory function against the HCC tumor in mice models without obvious toxicity, making it a promising drug candidate for HCC treatment.

Creation of an innovative diagnostic framework for hepatocellular carcinoma employing bioinformatics techniques focused on senescence-related and pyroptosis-related genes

BACKGROUND

Liver hepatocellular carcinoma (LIHC) continues to pose a major global health concern and is characterized by elevated mortality rates and a lack of effective therapies. This study aimed to explore differential gene expression linked to cellular senescence and pyroptosis in LIHC and to develop a prognostic risk model for use in clinical settings.

METHODS

We acquired datasets from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO). DESeq2 was used to identify differentially expressed genes associated with cell senescence and pyrodeath. The least absolute shrinkage and selection operator (LASSO) regression model was developed using cellular senescence- and pyroptosis-related differentially expressed genes (CSR&PRDEGs), and its predictive performance was evaluated with Kaplan-Meier survival analysis and time-dependent receiver operating characteristic (ROC) curves. We also performed various functional analyses of the genes. These findings were validated by real-time fluorescence quantitative polymerase chain reaction (PCR).

RESULTS

Using bioinformatics analysis, we developed a prognostic risk framework incorporating six critical genes: ANXA2, APOA1, EZH2, IGF2BP3, SQSTM1, and TNFRSF11B.The model demonstrated a statistically significant difference in overall survival between the high-risk and low-risk groups (p < 0.05). Additionally, real-time fluorescence quantitative PCR confirmed that genes ANXA2, APOA1, EZH2, IGF2BP3, SQSTM1, and TNFRSF11B were significantly overexpressed in the peripheral blood of patients with LIHC in comparison to normal volunteers, thereby validating the prognostic risk model's accuracy.

CONCLUSIONS

This study systematically elucidated the functions of genes associated with senescence and pyroptosis in LIHC cells. The constructed prognostic risk model serves to guide the development of personalized treatment plans, enhance patient management via risk stratification, facilitate the identification of high-risk patients, intensify monitoring or implement proactive interventions, thereby providing a novel perspective for the diagnosis and treatment of LIHC.

Discovery of potential VEGFR-2 inhibitors from natural products by virtual screening and molecular dynamics simulation

Hepatocellular carcinoma (HCC) is the most common cancer worldwide and vascular endothelial growth factor receptor-2 (VEGFR-2) is an important target in the development of inhibitors for the treatment of liver cancer. So far, however, there are no effective drugs targeting VEGFR-2 to achieve complete treatment of liver cancer. In this study, we employed molecular docking, molecular dynamics simulations, molecular mechanics generalized Born surface area (MM-GBSA) method, quantum mechanics/molecular mechanics (QM/MM) calculations and steered molecular dynamics simulations to discover the potential inhibitors from COCONUT database targeting VEGFR-2. The molecular docking analyses of 13 743 natural compounds targeting VEGFR-2 identified 96 molecules as promising candidates. Our molecular dynamics simulations revealed that only 5 candidate-docking systems remained stable over 100 ns of production run. Then, steered molecular dynamics simulations showed that CNP0076764, CNP0028810, CNP0177683 and CNP0107283 had higher mean force values than that of sorafenib, reflecting the high potential of candidate molecules. A detailed analysis of the binding modes revealed that Leu840, Val848, Lys868, Glu885, Leu889, Val899, Val916, Leu1035, Cys1045, Asp1046 and Phe1047 play key roles in binding the inhibitors. Overall, this study shows evidence that the four natural products obtained from the COCONUT database could be further used as anti-cancer inhibitors, which provides theoretical guidance for designing new drugs.

Disruption of Mitochondrial Dynamics and Stasis Leads to Liver Injury and Tumorigenesis

Background & Aims

Mitochondrial dysfunction has been implicated in aging and various cancer development. As highly dynamic organelles, mitochondria constantly undergo fission, mediated by dynamin-related protein 1 (DRP1, gene name Dnm1l ), and fusion, regulated by mitofusin 1 (MFN1), MFN2, and optic atrophy 1 (OPA1). However, whether and how dysregulation of mitochondria dynamics would be involved in liver pathogenesis and tumorigenesis is unknown.

Methods

Dnm1l Flox/Flox ( Dnm1l F/F ), Mfn1 F/F and Mfn2 F/F mice were crossed with albumin-Cre mice to generate liver-specific Dnm1l knockout (L- Dnm1l KO), L- Mfn1 KO, L- Mfn2 KO, L- Mfn1, Mfn2 double KO (DKO), and L- Mfn1, Mfn2, Dnm1l triple KO (TKO) mice. These mice were housed for various periods up to 18 months. Some mice also received hydrodynamic tail vein injections of a Sleeping Beauty transposon-transposase plasmid system with c-MYC and YAP . Blood and liver tissues were harvested for biochemical and histological analysis.

Results

L- Dnm1l KO mice had elevated serum alanine aminotransferase levels and increased hepatic fibrosis as early as two months of age. By 12 to 18 months, male L- Dnm1l KO mice developed spontaneous liver tumors, primarily hepatocellular adenomas. While female L- Dnm1l KO mice also developed liver tumors, their incidence was much lower. In contrast, neither L- Mfn1 KO nor L- Mfn2 KO mice had notable liver injury or tumorigenesis. However, a small portion of DKO mice developed tumors at 15-18 month-old. Increased DNA damage, senescence and compensatory proliferation were observed in L- Dnm1l KO mice but were less evident in L- Mfn1 KO, L- Mfn2 KO or DKO mice, indicating that mitochondrial fission is more important to maintain hepatocyte homeostasis and prevent liver tumorigenesis. Interestingly, further deletion of Mfn1 and Mfn2 in L- Dnm1l KO mice markedly abolished liver injury, fibrosis, and both spontaneous and oncogene-induced tumorigenesis. RNA sequencing and metabolomics analysis revealed significant activation of the cGAS-STING-interferon pathway and alterations in the tumor microenvironment pathways, alongside increased pyrimidine synthesis and metabolism in the livers of L- Dnm1l KO mice. Notably, the changes in gene expression and pyrimidine metabolism were considerably corrected in the TKO mice.

Conclusions

Mitochondrial dynamics and stability are essential for maintaining hepatic mitochondrial homeostasis and hepatocyte functions. Loss of hepatic DRP1 promotes liver tumorigenesis by increasing pyrimidine metabolism and activating the cGAS-STING-mediated innate immune response.

Treatment for hepatocellular carcinoma after immunotherapy

Immunotherapy has revolutionized the treatment landscape for advanced HCC, resulting in prolonged response and improved survival. With these results, a pressing question arises: what is the optimal treatment following first-line immunotherapy? Despite the benefits of immunotherapy, most patients will experience disease progression within six months and will require subsequent therapies. International guidelines recommend second-line multi-kinase inhibitors following progression on immunotherapy; however, this recommendation is primarily based on expert consensus rather than high-quality evidence. Nevertheless, real-world data indicate that these agents demonstrate similar efficacy and safety when used as first-line treatments. Conversely, it remains unclear whether continuing immunotherapy after progression is beneficial. In some cases, adding anti-CTLA-4 as salvage therapy has shown effectiveness. Molecular-directed therapies have also been tested, showing some initial promise, but further data is needed to confirm the benefits of this approach. Emerging evidence suggests that patients experiencing oligoprogression may benefit from local or locoregional therapies while continuing immunotherapy. In this review, we will discuss treatment strategies following progression after first-line immunotherapy.

Pharmacogenomic insights: IL-23R and ATG-10 polymorphisms in Sorafenib response for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Sorafenib is the first FDA-approved systemic therapy for advanced HCC. This study investigates the influence of IL-23R (rs7517847) and ATG-10 (rs10514231) genetic polymorphisms on Sorafenib response, survival outcomes, average tolerable dose, and adverse events. This prospective open-label cohort study included 100 HCC patients, assessing IL-23R and ATG-10 genotypes via real-time polymerase chain reaction (RT-PCR). Patient's responses were evaluated using modified RECIST criteria. Statistical analyses evaluated the association of genetic variants with response, progression-free survival (PFS), overall survival (OS), average tolerable Sorafenib dose, and adverse events. IL-23R TT carriers had the highest Sorafenib response rate (80%) compared to GT (13.3%) and GG (6.7%) (P = 0.021), while ATG-10 TT carriers had a 13.9-fold increased response likelihood (P = 0.001). The T allele in ATG-10 significantly predicted longer PFS (P = 0.025) and OS (P = 0.011), suggesting a potential prognostic role. IL-23R GG carriers received significantly higher Sorafenib doses than TT (P = 0.0174) and GT (P = 0.0227), whereas ATG-10 had no effect on dosage. However, its CT genotype was significantly associated with a higher risk of Hand-Foot Syndrome (P = 0.012), and independent of dose (P = 0.0018). IL-23R and ATG-10 polymorphisms influence Sorafenib response, survival, and tolerability in HCC patients. Genetic screening may improve personalized treatment strategies by optimizing Sorafenib efficacy and minimizing toxicity.This trial was registered on clinicaltrials.gov with registration number NCT06030895, registered on "September 11th, 2023," retrospectively.

Hepatocellular carcinoma: signaling pathways and therapeutic advances

Liver cancer represents a major global health concern, with projections indicating that the number of new cases could surpass 1 million annually by 2025. Hepatocellular carcinoma (HCC) constitutes around 90% of liver cancer cases and is primarily linked to factors incluidng aflatoxin, hepatitis B (HBV) and C (HCV), and metabolic disorders. There are no obvious symptoms in the early stage of HCC, which often leads to delays in diagnosis. Therefore, HCC patients usually present with tumors in advanced and incurable stages. Several signaling pathways are dis-regulated in HCC and cause uncontrolled cell propagation, metastasis, and recurrence of HCC. Beyond the frequently altered and therapeutically targeted receptor tyrosine kinase (RTK) pathways in HCC, pathways involved in cell differentiation, telomere regulation, epigenetic modification and stress response also provide therapeutic potential. Investigating the key signaling pathways and their inhibitors is pivotal for achieving therapeutic advancements in the management of HCC. At present, the primary therapeutic approaches for advanced HCC are tyrosine kinase inhibitors (TKI), immune checkpoint inhibitors (ICI), and combination regimens. New trials are investigating combination therapies involving ICIs and TKIs or anti-VEGF (endothelial growth factor) therapies, as well as combinations of two immunotherapy regimens. The outcomes of these trials are expected to revolutionize HCC management across all stages. Here, we provide here a comprehensive review of cellular signaling pathways, their therapeutic potential, evidence derived from late-stage clinical trials in HCC and discuss the concepts underlying earlier clinical trials, biomarker identification, and the development of more effective therapeutics for HCC.

Tolerability and Effectiveness of Regorafenib Treatment in Patients with Unresectable Hepatocellular Carcinoma: Real-World Data from the United States

Introduction

While several systemic therapies are available for unresectable hepatocellular carcinoma (uHCC), there is a lack of granular real-world evidence to support the efficacy and safety of these therapies. The REFINE study evaluated safety and effectiveness of regorafenib in a global population under real-world practice conditions. This sub-analysis describes the safety and effectiveness of regorafenib among the United States (US) subset of patients in the REFINE study relative to patients in the non-US subset.

Materials and Methods

REFINE was an international, prospective, multicenter observational study. Eligible patients were those with uHCC for whom a decision to treat with regorafenib had already been made. The primary study endpoint was the frequency of documented treatment-emergent adverse events (TEAEs). Additional endpoints included overall survival and progression-free survival. Groups were compared descriptively.

Results

Of 1005 patients, 65 were from the US and 940 were from other countries. 91% of patients in the US subset (n=59) and 92% in the non-US subset (n=862) experienced ≥1 TEAE. Common adverse events (AEs) included gastrointestinal disorders, fatigue, and hand-foot skin reaction. Median overall survival for patients in the US subset was 11.4 months (interquartile range [IQR]: 4.7-25.4) and 13.2 months (IQR: 5.8-26.3) in the non-US subset. Median progression-free survival was 3.4 months (IQR: 2.4-6.1) for patients in the US subset and 3.9 months (IQR: 2.2-8.5) in the non-US subset.

Conclusion

Regorafenib was associated with similar safety and effectiveness outcomes for patients in the US and non-US subsets of the REFINE study. Differences in the incidence of certain AEs may be due to differences in treatment management between study sites or baseline disease status. These findings are consistent with the phase 3 RESORCE trial and corroborate the safety and effectiveness of regorafenib as a subsequent-line treatment in US patients with uHCC.

To construct and validate a risk score model of angiogenesis-related genes to predict the prognosis of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors with high morbidity and mortality worldwide. Angiogenesis is essential for HCC progression and metastasis. Some angiogenesis-related genes promote this process, whereas other antiangiogenic genes inhibit HCC growth and metastasis. Therefore, finding new potential biomarkers for HCC prognosis prediction and treatment is essential. Public RNAseq and clinical data from TCGA and GEO database, download angiogenesis-related genes from the GeneCards, MSigDB database, through the single factor analysis of Cox, LASSO build risk score-Cox regression analysis model and external validation verified from the GEO. Cox regression analysis, Kaplan Meier (KM) curve, ROC curve, and decision-curve analysis will be used to evaluate and examine the risk score prediction effect of the model. GSVA analysis was used to assess the variation of gene sets between groups, and ClBERSOFT, ESTIMATE, and TIMER databases were used to analyze the immune infiltration in the single-cell level analysis of gene expression differences between cells. Finally, in the three pairs of HCC tissues and tissue adjacent to carcinoma by real-time fluorescent quantitative PCR (qRT_PCR) and western blotting (WB) to evaluate angiogenesis-related genes (ATP2A3 AEBP1 PNMA1, PLAT) expression level in HCC, and AEBP1 was knocked out in HCCLM3 cells, which is to study AEBP1 biological function in HCC. We established a prognostic risk assessment model based on 13 significant genes associated with HCC prognosis by Cox analysis and LASSO-Cox regression analysis. The median was used to divide these patients into high-risk and low-risk groups, and the prognosis of the high-risk group was worse than that of the low-risk group. Through the multivariate Cox regression analysis, it was found that the risk score was an independent predictor of overall survival (OS). The GSVA analysis suggested that the predicted high-risk population showed higher activity in the purine, pyrimidine, and riboflavin metabolic pathways. Compared with the low-risk group, the tumor microenvironment in the high-risk group showed a reduction in the number of cells promoting anti-tumor immunity and an increase in the number of cells inhibiting anti-tumor immunity, as well as a reduction in overall immune infiltration and matrix components. On the single-cell level, it was confirmed that the key genes (AEBP1, ATP2A3, PLAT, and PNMA1) expressed differently between liver cancer and adjacent tissue cell groups. Finally, qRT_PCR and WB results showed that ATP2A3, AEBP1, PNMA1, and PLAT were highly expressed in liver cancer tissue compared to adjacent tissue, and the proliferation, migration, and invasion of HCCLM3 cells were inhibited after knocking out AEBP1. We constructed novel risk score models as prognostic biomarkers for HCC, which has the potential to guide the development of more personalized treatment strategies for HCC patients. In addition, AEBP1 is a potential therapeutic target for HCC.

Cost-effectiveness of tislelizumab versus sorafenib as first-line treatment for unresectable hepatocellular carcinoma: a comparative analysis in China, the United States and Europe

BACKGROUND

Tislelizumab has emerged as a promising therapy for unresectable hepatocellular carcinoma (uHCC), although its economic viability across different healthcare systems remains uncertain.

AIM

This study compared the cost-effectiveness of tislelizumab versus sorafenib as a first-line treatment for uHCC from the perspectives of the healthcare systems of China, the United States and Europe.

METHOD

A partitioned survival model was developed using data from the RATIONALE-301 trial. Costs and utilities were sourced from local healthcare charges, publicly available databases, and published literature. Total costs, quality-adjusted life years, and incremental cost-effectiveness ratios (ICERs) were assessed. Price simulations were conducted to identify cost-effective pricing within established willingness-to-pay (WTP) thresholds. Sensitivity and scenario analyses were performed to test the robustness of the model.

RESULTS

Tislelizumab (priced at $1587.45/100 mg) was cost-effective in the US at a WTP threshold of $150,000, with an ICER of $108,812.52. In Europe, tislelizumab was cost-effective at a WTP threshold of $100,000, with an ICER of $94,880.40. For $186.18/100 mg in China, tislelizumab was cost-effective with an ICER of $14,206.80. Price simulation analyses showed that in the US, tislelizumab was favored when priced below $1438.30/100 mg at a $100,000 WTP threshold and below $2284.56/100 mg at a $150,000 WTP threshold. In Europe, it was favored below $1661.82/100 mg and $2501.93/100 mg for the same thresholds. In China, tislelizumab was cost-effective at a WTP threshold of $38,184 when priced below $582.11/100 mg.

CONCLUSION

Tislelizumab presents a cost-effective first-line treatment option for uHCC, potentially supporting its broader adoption in health policy. Future research should focus on long-term efficacy and real-world data to further validate these findings.

Comparison of Metastasectomy and Stereotactic Body Radiation Therapy for Pulmonary Oligometastasis From Hepatocellular Carcinoma: A Propensity Score-Weighted Analysis

PURPOSE

Although there is a growing role for local therapy in patients with hepatocellular carcinoma (HCC) and pulmonary oligometastasis, it remains unclear whether metastatectomy or stereotactic body radiation therapy (SBRT) is the more effective treatment for these patients. We aimed to compare the oncologic outcomes of metastasectomy and SBRT for HCC with pulmonary oligometastasis.

METHODS AND MATERIALS

We retrospectively analyzed 209 patients with HCC with 322 metastatic lung lesions who underwent either metastasectomy (150 patients with 241 lesions) or SBRT (59 patients with 81 lesions) between January 2008 and December 2018. Propensity score-based inverse probability of treatment weighting was used to minimize potential bias between the 2 groups.

RESULTS

The median follow-up duration was 39.8 months (range, 2.3-166.9 months). The 2-year rate of freedom from local progression was 98.2% in the metastasectomy group and 97.0% in the SBRT group (P = .197). The 2-year rates of overt systemic progression-free survival (PFS) (51.0% vs 46.1%; P = .274), PFS (26.3% vs 9.1%; P = .074), and overall survival (OS, 74.0% vs 57.6%; P = .006) were higher in the metastasectomy group. After the probability of treatment weighting adjustment, the 2-year rates of overt systemic PFS (50.8% vs 52.7%; P = .396), PFS (23.0% vs 24.7%; P = .478), and OS (72.6% vs 83.0%, P = .428) were not significantly different between the 2 groups. In multivariate analysis, viable intrahepatic lesions and the number of prior liver-directed therapies were found to be significant prognostic factors for OS and PFS. The time interval between HCC diagnosis and the development of pulmonary metastases was also significantly associated with OS.

CONCLUSIONS

Both metastasectomy and SBRT demonstrated excellent local control and comparable oncologic outcomes in patients with pulmonary oligometastasis from HCC. The treatment modality for these patients could be determined based on the individual patient's condition and intrahepatic disease status.

Atezolizumab plus bevacizumab as first-line treatment of unresectable hepatocellular carcinoma: interim analysis results from the phase IIIb AMETHISTA trial

BACKGROUND

The treatment of advanced hepatocellular carcinoma (HCC) with atezolizumab and bevacizumab led to significant improvements in overall survival (OS), progression-free survival (PFS), and response rate compared with sorafenib in the phase III IMbrave150 trial. The etiology of background liver disease can differ between Eastern and Western populations, leading to a potentially different impact of systemic therapies; therefore the unequal representation must be considered in the IMbrave150 trial. To provide further data on the safety and effectiveness of atezolizumab and bevacizumab, the phase IIIb AMETHISTA (Atezolizumab plus bevacizumab in METastatic HCC Italian Safety TriAl) ran in a Western (Italian) population of patients with advanced HCC. The results of the interim analysis are presented in this paper.

METHODS

AMETHISTA is a multicenter, phase IIIb, single-arm study evaluating the safety and effectiveness of atezolizumab and bevacizumab in an Italian population of patients with systemic treatment-naive HCC (ClinicalTrials.gov: NCT04487067). The primary objective was safety (incidence of grade 3-5 bleeding/hemorrhages). The main secondary objective was effectiveness.

RESULTS

A total of 152 patients were enrolled and 149 were treated. At the cut-off date, the median observation time was 13.4 months (interquartile range 8.3-15.5 months). The incidence of grade 3-5 bleeding/hemorrhages was 11.4%. Besides, results of other safety endpoints were consistent with the safety profile of atezolizumab plus bevacizumab, and the underlying disease, without any new safety observation. The median OS was 18.2 months (95% confidence interval 15.4 months to not evaluable); the median PFS was 8.5 months (95% confidence interval 7.5-11.2 months).

CONCLUSION

Results from the interim analysis are consistent with data from the IMbrave150 trial, and further confirm first-line atezolizumab plus bevacizumab as a standard of care for patients with systemic treatment-naive advanced and unresectable HCC.

Outcomes in the Asian subgroup of the phase III randomised HIMALAYA study of tremelimumab plus durvalumab in unresectable hepatocellular carcinoma

BACKGROUND & AIMS

In the global, phase III HIMALAYA study in unresectable hepatocellular carcinoma (uHCC), STRIDE (Single Tremelimumab Regular Interval Durvalumab) improved overall survival (OS) vs. sorafenib; durvalumab was non-inferior to sorafenib. HBV is the predominant HCC aetiology in most of Asia vs. HCV or non-viral aetiologies in Western countries and Japan. This analysis evaluated safety and efficacy outcomes for STRIDE and durvalumab monotherapy vs. sorafenib, in HIMALAYA participants enrolled in Asia, excluding Japan.

METHODS

In HIMALAYA, participants were randomised to STRIDE, durvalumab, or sorafenib. The Asian subgroup in this analysis included participants enrolled in Hong Kong, India, South Korea, Taiwan, Thailand, and Vietnam. OS, objective response rate (ORR; per RECIST, version 1.1), and safety were assessed in the Asian subgroup and in an exploratory subgroup of participants in Hong Kong and Taiwan.

RESULTS

The Asian subgroup included 479 participants randomised to STRIDE (n = 156), durvalumab (n = 167), or sorafenib (n = 156). OS was improved for STRIDE vs. sorafenib (hazard ratio [HR] 0.68; 95% CI 0.52-0.89). The OS HR for durvalumab vs. sorafenib was 0.83 (95% CI 0.64-1.06). In Hong Kong and Taiwan (n = 141), OS HRs for STRIDE vs. sorafenib and durvalumab vs. sorafenib were 0.44 (95% CI 0.26-0.77) and 0.64 (95% CI 0.37-1.08), respectively. In the Asian subgroup, ORR (including unconfirmed responses) was numerically higher for STRIDE (28.2%) and durvalumab (18.6%) vs. sorafenib (9.0%), and Grade 3/4 treatment-related adverse events were numerically lower for STRIDE (19.9%) and durvalumab (13.3%) vs. sorafenib (30.5%).

CONCLUSIONS

STRIDE improved outcomes vs. sorafenib in the Asian subgroup. These results support the benefits of STRIDE for participants with uHCC globally, including in the Asia-Pacific region.

CLINICAL TRIAL NUMBER

NCT03298451.

IMPACT AND IMPLICATIONS

The global, phase III HIMALAYA study found that the STRIDE (Single Tremelimumab Regular Interval Durvalumab) regimen improved overall survival (OS), including long-term OS vs. sorafenib, and that durvalumab monotherapy was non-inferior to sorafenib in participants with unresectable hepatocellular carcinoma (uHCC). However, there are differences in the aetiology and clinical practices related to HCC in parts of Asia, compared to Western countries and Japan, which could lead to differences in treatment outcomes between these regions. The results of this analysis demonstrate the benefits of STRIDE for participants in the Asia-Pacific region, consistent with the full, global study population. Overall, these findings continue to support the use of STRIDE in a diverse population, reflective of uHCC globally.

RECIST 1.1, mRECIST, and Choi criteria for evaluating treatment response and survival outcomes in hepatocellular carcinoma patients treated with atezolizumab plus bevacizumab

OBJECTIVES

We aimed to compare the early responder rates, defined as complete or partial responders, using response evaluation criteria in solid tumors (RECIST) 1.1, modified RECIST (mRECIST), and Choi criteria in advanced HCC patients treated with atezolizumab-bevacizumab (atezo-bev), and to correlate them with progression-free survival (PFS) and overall survival (OS).

METHODS

This retrospective study included advanced HCC patients treated with ≥ 3 cycles of atezo-bev. Two reviewers assessed responses using RECIST 1.1, mRECIST, and Choi criteria at 1st follow-up imaging. Kaplan-Meier curves with log-rank tests evaluated and compared PFS and OS. Cox proportional hazard models identified survival outcome predictors. Kappa statistics assessed inter-reader agreement.

RESULTS

We evaluated 77 patients (65 men; mean age, 62.8 ± 12.3 years). Choi's criteria revealed the highest early responders rate (53.2%), exceeding mRECIST (32.5-33.8%) and RECIST 1.1 (24.7-26.0%), with an excellent agreement in all criteria (κ, 0.85-0.95). Across criteria, a consistent number of patients progressed (23-26) and was associated with significantly poor OS (ps ≤ 0.049). Responders by any criteria showed longer PFS (ps ≤ 0.009), and 1-year OS (ps ≤ 0.01). Choi criteria linked to significantly better OS without landmark (p = 0.003), with 1-year OS rates at 76.9% for responders vs 38.1% for non-responders. Cox analysis identified responders by Choi criteria as a significant OS predictor.

CONCLUSION

Choi criteria identified more early responders than RECIST 1.1 and mRECIST, significantly correlating with improved OS. Choi criteria could be considered as a formal response assessment criterion for the emerging atezo-bev systemic treatment.

CLINICAL RELEVANCE STATEMENT

For atezo-bev treatment of advanced HCC, more comprehensive response criteria, such as Choi criteria, could be effective in identifying early responders and predicting survival outcomes along with RECIST 1.1 and mRECIST.

KEY POINTS

Choi criteria identified a higher rate of early responders compared to mRECIST and RECIST1.1 following atezo-bev treatment. Responders by all criteria had longer PFS and 1-year OS, and only those by Choi criteria experienced longer OS without landmark time. Choi criteria, with RECIST 1.1 and mRECIST, is an effective response assessment tool for atezo-bev treatment.

Stereotactic Body Radiotherapy vs Sorafenib Alone in Hepatocellular Carcinoma: The NRG Oncology/RTOG 1112 Phase 3 Randomized Clinical Trial

Importance

Most patients with locally advanced hepatocellular carcinoma (HCC) recur within the liver following systemic therapy.

Objective

To determine whether stereotactic body radiation therapy (SBRT) improves outcomes in patients with locally advanced HCC compared with sorafenib alone.

Design, Setting, and Participants

This multicenter phase 3 randomized clinical trial randomized patients with HCC 1:1 to sorafenib or SBRT followed by sorafenib, stratified by performance status, liver function, degree of metastases, and macrovascular invasion. Eligible patients had HCC unsuitable for or refractory to standard local-regional therapies and were candidates for first-line systemic therapy. Data were collected from April 2013 to March 2021, and data were analyzed from July 2022 to August 2023.

Intervention

Personalized SBRT, 27.5 to 50 Gy in 5 fractions.

Main Outcomes and Measures

The primary end point was overall survival (OS). Secondary end points were progression-free survival (PFS), adverse events, and quality of life.

Results

Of 193 patients randomized, 177 were eligible. Accrual was stopped early due to a change in standard-of-care systemic therapy. Of 177 included patients, 150 (84.7%) were male, and the median (IQR) age was 66 (60-72) years. Macrovascular invasion was seen in 131 (74.0%). As of July 1, 2022, the median OS was 12.3 months (90% CI, 10.6-14.3) with sorafenib vs 15.8 months (90% CI, 11.4-19.2) following SBRT and sorafenib (hazard ratio [HR], 0.77; 90% CI, 0.59-1.01; 1-sided P = .06). Adjusting for stratification factors, OS was improved with SBRT (HR, 0.72; 95% CI, 0.52-0.99; 2-sided P = .04). Median PFS was improved from 5.5 months (95% CI, 3.4-6.3) with sorafenib to 9.2 months (95% CI, 7.5-11.9) with SBRT and sorafenib (HR, 0.55; 95% CI, 0.40-0.75; 2-sided P < .001). Treatment-related grade 3 or higher adverse events were seen in 37 of 88 (42%) and 39 of 83 (47%) of patients treated with sorafenib vs SBRT and sorafenib, respectively (P = .52). There were 2 treatment-related deaths in the sorafenib group (death not otherwise specified and liver failure) and 1 in the SBRT and sorafenib group (lung infection). At 6 months, improved quality of life was seen in 2 of 20 (10%) and 6 of 17 (35%) of patients treated with sorafenib and SBRT and sorafenib, respectively.

Conclusions and Relevance

In this phase 3 randomized clinical trial, among patients with locally advanced HCC, SBRT was associated with a clinically important but not statistically significant improved overall survival compared with sorafenib alone.

Trial Registration

ClinicalTrials.gov Identifier: NCT01730937.

Hepatic Arterial Infusion Chemotherapy Enhances the Efficacy of Lenvatinib Plus PD-1 Inhibitors in Hepatocellular Carcinoma Patients with Tumor Thrombosis in the Inferior Vena Cava and/or Right Atrium

RATIONALE AND OBJECTIVES

Hepatocellular carcinoma (HCC) with invasion into the inferior vena cava (IVC) or the right atrium (RA) presents significant therapeutic challenges due to its rapid progression and limited available treatments.

MATERIALS AND METHODS

This retrospective study evaluated the effectiveness of hepatic arterial infusion chemotherapy alongside lenvatinib and PD-1 inhibitors (HAIC-Len-PD1) compared to treatment with only lenvatinib and PD-1 inhibitors (Len-PD1). A total of 115 patients with HCC and IVC or RA invasion were included. We analyzed groups for median overall survival (OS) and progression-free survival (PFS) through the Kaplan-Meier method, along with tumor response rates, disease control rates, and adverse event frequencies.

RESULTS

The HAIC-Len-PD1 treatment showed a marked improvement in median OS (22.2 vs. 14.4 months; P = 0.007) and median PFS (13.8 vs. 5.1 months; P = 0.001) over the Len-PD1 regimen. There was also a higher overall response rate (68.7% vs. 37.5%; P < 0.05) and disease control rate (92.5% vs. 75%; P < 0.05) observed in the HAIC-Len-PD1 group. A subgroup analysis demonstrated consistent survival benefits across diverse patient demographics. Although the incidence of adverse events was higher in the HAIC-Len-PD1 group, these were generally manageable and well-tolerated.

CONCLUSION

The combined regimen of HAIC, lenvatinib, and PD-1 inhibitors may improve survival and tumor management in HCC patients with IVC or RA invasion, suggesting a potential therapeutic option for this critically at-risk group. Further research in the form of randomized controlled trials are needed to verify these findings for advanced-stage HCC with vascular compromise.

NUSAP1 Promotes Immunity and Apoptosis by the SHCBP1/JAK2/STAT3 Phosphorylation Pathway to Induce Dendritic Cell Generation in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common type of liver cancer and is associated with high morbidity and mortality rates. The aims of this study were to investigate the immune-promoting action of nucleolar and spindle-associated protein 1 (NUSAP1) and identify an immunotherapy target for HCC. The Cancer Genome Atlas (TCGA) was used to analyze interaction molecules and immune correlation. The interaction between NUSAP1 and SHC binding and spindle associated 1 (SHCBP1) was examined. The role of the SHCBP1/Janus kinase 2/signal transducer and activator of transcription 3 (SHCBP1/JAK2/STAT3) pathway in this process was explored. After co-culture with HCC cell lines, the differentiation of peripheral blood mononuclear cells (PBMCs) into dendritic cells (DC) was evaluated by measuring the expression of surface factors CD1a and CD86. Pathological tissues from 50 patients with HCC were collected to validate the results of cell experiments. The expression levels of CD1a and CD86 in tissues were also determined. The results show that NUSAP1 interacted with SHCBP1 and was positively correlated with DC. In HCC cell lines, an interaction was observed between NUSAP1 and SHCBP1. It was verified that NUSAP1 inhibited the JAK2/STAT3 phosphorylation pathway by blocking SHCBP1. After co-culture, the levels of CD1a and CD86 in PBMC were elevated. In the clinical specimens, CD1a and CD86 expression levels were significantly higher in the high-NUSAP1 group versus the low-NUSAP1 group. In Summary, NUSAP1 enhanced immunity by inhibiting the SHCBP1/JAK2/STAT3 phosphorylation pathway and promoted DC generation and HCC apoptosis. NUSAP1 may be a target of immunotherapy for HCC.

An open-label, randomized, controlled trial on the benefit of β-hydroxy-β-methyl butyrate, l-arginine, l-glutamine combination beverages and locomotion training as supportive care for the treatment of unresectable hepatocellular carcinoma using lenvatinib: A pilot study (HELLO study)

INTRODUCTION

Hand-foot-skin reaction (HFSR) is the most common side effect of multi-tyrosine kinase inhibitor therapy for unresectable hepatocellular carcinoma (uHCC). Sarcopenia has been reported to be a poor prognostic factor for HCC. Here, we performed a randomized controlled trial (RCT) of the efficacy of a β-hydroxy-β-methyl butyrate/l-arginine/l-glutamine (HMB/Arg/Gln) beverage and locomotion training as supportive care in the treatment of uHCC with lenvatinib.

METHODS

A total of 20 patients were enrolled from the jRCTs031190252 trial in this pilot study. HFSR was the primary endpoint, and other adverse events and skeletal muscle index at the third lumbar level (L3-SMI) were secondary endpoints.

RESULTS

Twelve patients had albumin-bilirubin grade 1, and eight had grade 2. No difference in HFSR was observed. Although interesting differences were observed in the secondary endpoints, a slight retention of L3-SMI values in the intervention group compared with that in the control group was observed (96.5 % vs. 89.9 %, p = 0.407).

CONCLUSION

Although the HMB/Arg/Gln beverage and locomotion training did not reduce adverse events caused by lenvatinib, they might be useful in maintaining skeletal muscle mass. Further validation studies with a larger number of patients are warranted.

An Indirect Treatment Comparison of Lenvatinib for the First-Line Treatment of Patients with Unresectable Hepatocellular Carcinoma

INTRODUCTION

This study compared the relative efficacy of first-line lenvatinib, a standard-of-care treatment for unresectable hepatocellular carcinoma (uHCC), vs licensed/license in-progress comparators. Using inverse probability of treatment weighting (IPTW) and network meta-analysis (NMA), updated evidence for lenvatinib monotherapy from LEAP-002, in addition to evidence from REFLECT, was included in the analyses.

METHODS

Randomized controlled trials (RCTs) were identified via systematic review. REFLECT and LEAP-002 investigated lenvatinib in uHCC, with patient-level data available for each; however, only REFLECT included a comparator arm of interest (sorafenib). The lenvatinib arm from LEAP-002 was adjusted to match aggregate data for confounding factors from REFLECT using IPTW. Weighted Cox regressions, including matching variables as covariates, were used to derive hazard ratios (HRs) for overall survival (OS) and progression-free survival (PFS). These HR estimates were included in Bayesian NMAs to compare lenvatinib with comparators; survival was significantly improved if the 95% credible interval for the HR did not include 1.0. Scenario analyses explored alternative choices for IPTW estimators.

RESULTS

Eight RCTs (including REFLECT) and the single-arm adjusted lenvatinib data from LEAP-002 were included in the NMA base case. Lenvatinib demonstrated significant improvement in OS compared with sorafenib 400 mg twice daily (BID) and significant improvement in PFS compared with sorafenib 400 mg BID, tremelimumab 300 mg plus durvalumab 1500 mg every 4 weeks (Q4W), and durvalumab 1500 mg Q4W.

CONCLUSIONS

These results suggest that patients with uHCC treated with lenvatinib have similar or significantly improved OS and PFS compared with licensed/license in-progress therapies.

Second-line treatment patterns and outcomes in advanced HCC after progression on atezolizumab/bevacizumab

Background & Aims

Atezolizumab/bevacizumab (A/B) is now a standard first-line treatment for advanced hepatocellular carcinoma (HCC), but the optimal second-line regimen is not known. We evaluated real-world treatment patterns and outcomes to investigate factors associated with post-progression survival (PPS).

Methods

In this multicenter, international, retrospective study, we examined clinical characteristics and outcomes of patients with advanced HCC who progressed on first-line A/B. The primary outcome of PPS was defined as time from first radiographic progression on A/B to death.

Results

A total of 406 patients alive after progression on first-line A/B were included in the final analysis, of whom 45.3% (n = 184) received best supportive treatment (BST) and 54.7% (n = 222) continued active systemic treatment. In the second line, 155 patients were treated with tyrosine kinase inhibitors (TKIs), 45 with immune checkpoint inhibitor (IO)-based regimens, and 3 had missing data. Median PPS of the whole cohort (mPPS) was 6.0 months (95% CI 5.2-7.2). On multivariate Cox regression analysis, absence of portal vein tumor thrombus, ECOG <2, and continued active treatment were predictors of better PPS. mPPS was significantly longer for patients who continued active treatment vs. BST (9.7 vs. 2.6 months; HR 0.41, p <0.001). In the second-line setting, patients treated with TKIs had a numerically shorter mPPS compared to those treated with IO (8.4 vs. 14.9 months; HR 1.37, p = 0.256).

Conclusions

Continuation of active therapy after A/B progression was independently associated with better survival even after adjusting for baseline disease characteristics. mPPS with IO-based therapy exceeded a year, suggesting that IO continuation post-progression may retain benefit. The precise sequencing of TKI and IO regimens warrants further investigation.

Impact and implications

There is currently a lack of level 1 data on second-line treatment options for patients with advanced hepatocellular carcinoma who progress after frontline atezolizumab plus bevacizumab, as all second-line approvals were established during the frontline sorafenib era. Our study aims to fill in some of the knowledge gap by investigating real-world patient outcomes in the second-line treatment setting. Findings from this study show that patients who continued active treatment had improved post-progression survival compared to those who received best supportive care, and medication regimens incorporating tyrosine kinase inhibitors as well as immunotherapy agents were active. These results can help inform clinicians of possible treatment options for patients who progress after frontline atezolizumab plus bevacizumab while we await maturing data from randomized-controlled trials.

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.