Early radiological response evaluation with response evaluation criteria in solid tumors 1.1 stratifies survival in hepatocellular carcinoma patients treated with lenvatinib

Radiographic and serologic response in patients with unresectable hepatocellular carcinoma receiving systemic antineoplastic treatments: A trial-level analysis

BACKGROUND

In a disease like unresectable hepatocellular carcinoma, overall survival is an inadequate outcome measure for evaluating the effectiveness of treatments given the high risk of death from liver failure. There is an unmet need for reliable alternative end points for clinical trials and daily clinical practice. To evaluate treatment response in patients with unresectable or metastatic hepatocellular carcinoma (mHCC), imaging-related end points are often used, whereas serologic end points have been developed for patients with serum alpha-fetoprotein levels >20 ng/mL. The objective of this study was to evaluate clinical trials that report concomitant assessment of radiographic and serologic response in patients with mHCC.

METHODS

After a systematic review, studies that evaluated response according to radiographic and serologic criteria were selected. A correlation between progression-free survival (PFS) and overall survival (OS) was performed, and a linear regression of each response-related outcome measure with OS was reported. Finally, the effect of eight baseline variables on OS and response-related measures was evaluated.

RESULTS

Twenty-six studies were included, including 16 first-line studies and 10 second-line studies. PFS and response rates demonstrated a significant relationship with OS, whereas disease control rates did not. The responses were correlated with OS, particularly in the first-line setting, after targeted therapy, and whenever assessment was early. Among the baseline variables, only performance status had a prognostic role, whereas hepatitis B virus-related liver disease was associated with higher radiographic response rates.

CONCLUSIONS

PFS and radiographic and serologic response rates appear to be reliable intermediate end points in patients with mHCC who are undergoing systemic antineoplastic therapy. However, the serologic response is available earlier.

The α-RECIST (RECIST 1.1 Combined With Alpha Fetoprotein): A Novel Tool for Identifying Tumor Response of Conversion-Radiotherapy for Unresectable Hepatocellular Carcinoma Before Hepatectomy

Purpose

To develop a novel criterion based on the response evaluation criteria in solid tumors (RECIST) 1.1 and alpha fetoprotein (AFP) and evaluate its performance in tumor response for patients with unresectable hepatocellular carcinoma (uHCC) receiving conversion-radiotherapy before hepatectomy.

Method

From June 2012 to December 2020, a total of 39 patients with uHCC, who received intensity-modulated radiotherapy (IMRT) before hepatectomy, were retrospectively included in this study. Pre- and post-treatment contrast-enhanced magnetic resonance imaging (CE-MRI) scans were performed in all patients. Eight modified criteria were developed with the combination of RECIST 1.1, modified RECIST (mRECIST), and the percentage change of AFP, baseline AFP. The endpoint events were recurrence-free survival (RFS).

Results

The median RFS and OS was 26.5 (IQR, 15.7-43.1), 38.8 (IQR, 18.4-53.6) months. An optimal revised evaluation criterion named α-RECIST (alpha fetoprotein-RECIST 1.1) was developed by combining the RECIST 1.1 with the AFPΔ (cut-off value, 76%). Patients defined as responders by α-RECIST showed significantly better RFS and OS than those defined as non-responders (p = 0.035, 0.048). The other criteria (RECIST 1.1, mRECIST, αΔ-mRECIST, α&Δ-RECIST, α&Δ-mRECIST, αBL-RECIST, αBL-mRECIST, α&BL-RECIST, α&BL-mRECIST) all failed to identify responders from non-responders (p = 0.405, 0.201, 0.773, 0.424, 0.266, 0.060, 0.721, 0.644, 0.910, respectively) when correlated with RFS. Responders according to α-RECIST showed significant better RFS compared to non-responders [HR, 0.31 (95% CI: 0.10, 0.98); p=0.046], but no statistical significance was observed in terms of OS [HR, 0.33 (95% CI: 0.11, 1.05); p = 0.06].

Conclusions

Patients identified as responders by α-RECIST provided significant better RFS. The α-RECIST criteria might be a promising tool for identifying tumor response of conversion-radiotherapy for unresectable hepatocellular carcinoma before hepatectomy.

Different Radiological Criteria for Early Tumor Response Evaluation in Patients With Unresectable Hepatocellular Carcinoma Treated With Anti-PD-1 Antibody Plus Bevacizumab

Purpose

We aimed to compare different radiological criteria in evaluating the early tumor response of patients with unresectable hepatocellular carcinoma (uHCC) treated with an anti-programmed cell death protein 1 (PD-1) antibody plus bevacizumab.

Method

From October 2018 to January 2020, 58 patients [49 (84.5%) men, age = 55.2 ± 10.6 years] receiving both anti-PD-1 antibody and bevacizumab were retrospectively included. Pre- and the first posttreatment contrast-enhanced computed tomography (CE-CT) scans were performed in all patients. The Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST 1.1), modified RECIST (mRECIST), Choi, and the revised Choi (rChoi) criteria were applied to evaluate tumor response. The endpoint event was defined as overall survival (OS).

Results

Six (10.3%), 9 (15.5%), 30 (51.7%), and 12 (20.7%) patients were diagnosed as responders by RECIST 1.1, mRECIST, Choi, and rChoi, respectively. The RECIST 1.1 and mRECIST criteria failed to correlate the evaluation categories with OS (p = 0.130 and 0.253, respectively), while both Choi and rChoi significantly correlated with OS (p = 0.002 and 0.006, respectively). Among the four criteria, only those patients identified as responders by Choi (p = 0.0005) and rChoi (p = 0.005) showed significantly better OS than the non-responders. The cumulative 1- and 2-year OS rates by Choi were 93.3% and 79.8% in responders and 69.3% and 30.3% in non-responders, respectively; these rates were 100.0% and 100.0% in responders and 74.9% and 43.1% in non-responders by rChoi, respectively.

Conclusions

The evaluation of early tumor response using Choi and rChoi instead of RECIST 1.1 and mRECIST significantly correlated with the OS of patients with uHCC treated with an anti-PD-1 antibody plus bevacizumab. Moreover, patients identified as responders by Choi and rChoi showed significantly better OS than the non-responders.

Conversion surgery for hepatocellular carcinoma after tyrosine kinase inhibitor treatment

Background and Aim

Conversion surgery (CS), which aims to cure after systematic therapy, is only scarcely reported in the field of hepatocellular carcinoma (HCC). However, advancements in systemic therapy for HCC are expected to increase the candidates eligible for CS because of the higher response rate. The aim of this study was to clarify the characteristics of patients who underwent CS after tyrosine kinase inhibitor (TKI) therapy.

Methods

In all, 364 patients who were treated with first‐line sorafenib (SOR; n = 292) and lenvatinib (LEN; n = 72) from July 2009 to October 2020 were retrospectively enrolled. The endpoint of this analysis was overall survival (OS), and factors associated with CS are revealed.

Results

Six patients underwent CS after TKI therapy, and of these four (1.4%) and two (2.7%) patients received SOR and LEN, respectively. At baseline, patients who underwent CS were significantly younger (median 52 [range, 46–83] years of age, P = 0.019), and their etiology included viral hepatitis, especially hepatitis B virus (HBV) (P = 0.049). Improvements or maintenance of preoperative modified albumin–bilirubin grade from baseline were observed in five (83.3%) patients, and partial radiologic response was observed in four (66.7%) patients. The median OS and 3‐year survival rate of patients treated with CS were “not reached” and 80.0%, respectively.

Conclusion

The patients who underwent CS after TKI therapy for HCC experienced long survival, were relatively young, and exhibited radiologic response to TKIs, and their liver function was either maintained or improved. Therefore, CS may lead to a better prognosis in patients with advanced HCC.

Clinical evaluation of Elecsys PIVKA-II for patients with advanced hepatocellular carcinoma

Background

Prothrombin induced by vitamin K absence-II (PIVKA-II) was reported as a diagnosis and prognosis marker for hepatocellular carcinoma (HCC). Although the development of systemic therapies for advanced HCC has been remarkable, the role of PIVKA-II is unclear. This prospective study aimed to verify Elecsys PIVKA-II compared with Lumipulse PIVKA-II in a cohort with advanced HCC undergoing systemic therapy.

Methods

A total of 62 HCC patients who were treated with atezolizumab and bevacizumab (ATZ+BEV) and molecular targeted agents (MTAs) were prospectively enrolled at Musashino Red Cross Hospital from January 2020 to December 2020. A total of 208 serum samples from 52 patients were tested using Elecsys PIVKA-II and Lumipulse PIVKA-II assays. Furthermore, the relationship of Elecsys PIVKA-II and progression-free survival (PFS) was investigated with 48 patients (24 ATZ+BEV and 24 MTAs) whose Lumipulse PIVKA-II levels were >40 mAU/mL.

Results

In the test accuracy analysis, the Elecsys assay has a correlation coefficient (R) of 0.92 compared with that of the Lumipulse assay (ATZ+BEV, 0.95; MTAs, 0.91). In the PFS analysis, the number of patients who received ATZ+BEV and MTAs as first- and late-line therapy were 9 and 13, and 15 and 11, respectively. The PIVKA-II response was defined for patients who had a reduction in the Elecsys PIVKA-II level on the first month of treatment evaluation. The PFS of patients with Elecsys PIVKA-II response was significantly longer than that of nonresponse patients (5.8 months vs 3.8 months, p = 0.0205).

Conclusion

The Elecsys PIVKA-II was not only as useful as the Lumipulse PIVKA-II but also for stratifying the PFS of patients with advanced HCC.