Identification of clinical biomarkers for patients with advanced hepatocellular carcinoma receiving sorafenib

A case report: Long-term complete response of metastatic hepatocellular carcinoma obtained after discontinuation of 2-month sorafenib monotherapy

A 69-year-old woman who had a history of chronic hepatitis C, autoimmune hemolytic anemia and myelodysplastic syndrome was treated with sorafenib at a daily dose of 400 mg for HCC with multiple lung metastases. Nonetheless, elevated serum tumor markers further increased (alpha fetoprotein from 121,100 to 348,660 ng/ml and protein induced by vitamin K absence/antagonist-II from 3435 to 29,357 mAU/ml), and lung metastatic lesions on chest X-ray showed no improvement after 2 months of sorafenib treatment. Sorafenib was discontinued because of adverse events with diarrhea, fatigue, and severe anemia due to bleeding from stomach telangiectasia. Hand-foot syndrome was mild. Thereafter, the tumor markers rapidly decreased to almost normal range, and the lung and liver tumors markedly shrunk and disappeared without any other cancer treatments. Her tumors remained in complete remission for 17 months until an intrahepatic recurrence occurred. This unique course of metastatic HCC indicated that antitumor mechanisms other than the direct anticancer effect of sorafenib contributed to tumor shrinkage.

Tyrosine Kinase Inhibitor-Induced Hypertension: Role of Hypertension as a Biomarker in Cancer Treatment

:

Cancer treatment is an area of continuous improvement. Therapy is becoming more targeted and the use of anti-angiogenic agents in multiple cancers, specifically tyrosine kinase inhibitors (TKIs), has demonstrated prolonged survival outcomes compared with previous drugs. Therefore, they have become a well-established part of the treatment.

:

Despite good results, there is a broad range of moderate to severe adverse effects associated with treatment. Hypertension (HTN) is one of the most frequent adverse effects and has been associated with favourable outcomes (in terms of cancer treatment) of TKI treatment.

:

High blood pressure is considered a class effect of TKI treatment, although the mechanisms have not been fully described. Three current hypotheses of TKI-associated HTN are highlighted in this narrative review. These include nitric oxide decrease, a change in endothelin-1 levels and capillary rarefaction.

:

Several studies have investigated HTN as a potential biomarker of TKI efficacy. HTN is easy to measure and adding this factor to prognostic models has been shown to improve specificity. HTN may become a potential biomarker in clinical practice involving treating advanced cancers. However, data are currently limited by the number of studies and knowledge of the mechanism of action.

Systematic review with meta-analysis: the critical role of dermatological events in patients with hepatocellular carcinoma treated with sorafenib

BACKGROUND

The positive results of the REFLECT trial in terms of survival (sorafenib vs lenvatinib) offer a new first-line option for hepatocellular carcinoma. Additionally, the expected results of immunotherapy could change the first-line treatment in hepatocellular carcinoma or the clinical trial design in first and second-line.

AIMS

To evaluate the impact of dermatologic adverse events under sorafenib in hepatocellular carcinoma patients as a clinical marker to predict prognosis and critically evaluate outcomes within trials.

METHODS

A systematic search of original articles published until October 2018 was performed using PubMed/MEDLINE and a meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 393 studies were identified and 13 articles with 2035 patients (79.5% Child-Pugh-A, 73.2% BCLC-C) were selected for qualitative and quantitative analysis. The main type of dermatologic adverse events was hand-foot skin reaction (47.7%) but other dermatologic adverse events were reported in 31.7% of the cases. Presence of dermatologic adverse events was associated with a lower mortality when compared with those patients without them (pooled Hazard Ratio for the univariate analysis 0.45 (95% CI: 0.38-0.53) and there was no heterogeneity for the analysis (P = 0.511; I²  = 0.0%). Refuting this association would require the future report of 1370 negative studies.

CONCLUSIONS

This meta-analysis shows a clinically meaningful association between dermatologic adverse events and a higher probability of longer survival. These data support the use of dermatologic adverse events in the clinical decision-making when informing the prognosis and when systemic treatment is decided.

Factors Affecting Therapeutic Effects in 17 Patients with Advanced Hepatocellular Carcinoma Who Were Treated with Sorafenib for More than 12 Months

Background and Objective

Sorafenib is recommended for treating advanced hepatocellular carcinoma. However, it is frequently discontinued because of adverse events, which greatly affects its therapeutic effects. Furthermore, because patients treated with sorafenib for a long period can presumably tolerate adverse events, this study aimed to identify their characteristics and analyze factors affecting the therapeutic effects of the drug.

Subjects and Methods

Seventeen patients with hepatocellular carcinoma who received sorafenib for 12 months or longer at our hospital between January 2009 and October 2015 were included. In these 17 patients, factors affecting the time to untreatable progression were analyzed using a Cox proportional hazards model, Kaplan-Meier curve, and log-rank test.

Results

In the 17 patients, the mean sorafenib dose was 433 mg/day. The drug was discontinued in 12 patients, 9 (75%) of whom discontinued it because of progressive disease. The median time to untreatable progression was 23.1 months. The contributors to favorable therapeutic effects included administration of at least two sessions of concomitant therapy after initiating sorafenib therapy, a low neutrophil-to-lymphocyte ratio, and a decreased total bilirubin level.

Conclusion

Achieving favorable therapeutic effects of sorafenib requires strict dose adjustment that allows better control of adverse events and long-term administration of the drug. Furthermore, combining sorafenib with other therapies, a low neutrophil-to-lymphocyte ratio, and a decreased total bilirubin level are useful predictors of favorable effects.

Cutaneous toxicity as a predictive biomarker for clinical outcome in patients receiving anticancer therapy

The relationship between treatment outcome and cutaneous toxicity induced by anticancer therapy has gained attention in the past decade. In this article, we have provided an overview of the 3 main classes of anticancer agents-specifically, molecularly targeted kinase inhibitors, immune checkpoint inhibitors, and cytotoxic chemotherapeutics-and described the data evaluating the association between cutaneous toxicity induced by these agents and survival benefit. Although preliminary studies are promising with regard to the potential role of cutaneous toxicities as a surrogate biomarker of efficacy of treatment, larger prospective studies are needed to confirm this relationship. Dermatologists have a unique opportunity to collaborate with oncologists in the multidisciplinary treatment paradigm by helping to identify and manage these dermatologic events in patients with cancer. A heightened awareness of these toxicities is critical, as it can potentially allow recognition of the efficacy of anticancer therapy and may influence treatment decisions and patient outcomes.

Treatment at a high-volume centre is associated with improved survival among patients with non-metastatic hepatocellular carcinoma

BACKGROUND & AIMS

The association between case volume and outcomes is well-documented for several cancer types. However, it is unknown if patients with hepatocellular carcinoma treated at high-volume centres have improved overall survival.

METHODS

About 135 442 patients diagnosed with hepatocellular carcinoma between 2004-2014 were identified in the Commission on Cancer's National Cancer Database and 53 795 patients were excluded for metastatic or node-positive disease. Average annual case volume was calculated as the total number of cases treated per centre from 2004-2014 and dividing by 10. Receiver operating characteristic curves showed the most significant case number threshold between high-volume centres and remaining centres. Univariate and multivariate analyses were performed using Cox regression analysis to determine factors associated with improved survival. Kaplan-Meier curves and log-rank tests were used for overall survival estimates.

RESULTS

A total of 81 647 patients with stage I-III hepatocellular carcinoma were treated at a total of 1218 centres. The median [range] case volume per year averaged over the 10-year study period was 48.6 [0.1-205.5]. High-volume centres treated >114 cases of hepatocellular carcinoma annually while remaining centre treated ≤114 cases. Median survival for patients treated in high-volume centres and remaining centres were 31.9 and 16.6 months respectively (Log Rank P < .001). On multivariate analysis, average annual case volume was significantly associated with improved survival.

CONCLUSIONS

Receiving treatment at a high-volume centre is significantly associated with survival for patients with non-metastatic disease. Improved survival at high-volume centres may be related to access to a variety of treatment modalities, multidisciplinary evaluation, and/or subspecialty expertise.

Impact of baseline characteristics on outcomes of advanced HCC patients treated with sorafenib: a secondary analysis of a phase III study

BACKGROUND

The current study aims to investigate the impact of baseline characteristics on the outcomes of sorafenib-treated advanced Hepatocellular carcinoma (HCC) patients in the setting of a clinical trial.

METHODS

This is a secondary analysis of the comparator arm (sorafenib arm) of the NCT00699374 study which is a phase III multicenter study conducted between 2008 and 2010. The univariate probability of overall and progression-free survival was assessed among different patient subsets through Kaplan-Meier analysis and log-rank testing. Multivariate analysis of factors affecting overall and progression-free survival was then conducted through Cox regression analysis.

RESULTS

All patients within the comparator (sorafenib) arm were included in the analysis (N = 544 patients). In multivariate analysis, prior hepatectomy (P = 0.028), prior locoregional treatment (P = 0.048), grade 1 ALBI score (P < 0.001), ECOG performance score of 0 (P < 0.001), BMI ≥ 25 (P = 0.026), AFP < 200 (P = 0.001), and no extra-hepatic spread (P = 0.007) were associated with better overall survival. Likewise, in multivariate analysis, non-Asian race (P = 0.004), grade 1 ALBI score (P = 0.001), ECOG performance score of 0 (P = 0.006), and no extra-hepatic spread (P = 0.005) were associated with better progression-free survival. Moreover, development of high-grade hand-foot skin reaction was associated with a statistically significant improvement in overall survival (P = 0.003), which was further confirmed in a multivariate analysis adjusted for other relevant baseline factors (P = 0.002).

CONCLUSION

Within a cohort of highly selected advanced HCC patients, baseline patient-, liver-, and disease-centered variables play an important role in predicting patient outcomes. This information is important in terms of therapeutic decision-making and patient counseling.

An internally validated new clinical and inflammation-based prognostic score for patients with advanced hepatocellular carcinoma treated with sorafenib

BACKGROUND

Sorafenib is a standard treatment for patients (pts) with advanced hepatocellular carcinoma (aHCC), although the clinical benefit is heterogeneous between different pts groups. Among novel prognostic factors, a low baseline neutrophil-to-lymphocyte ratio (bNLR) and early-onset diarrhoea have been linked with a better prognosis.

PURPOSE

To identify prognostic factors in pts with aHCC treated with 1st-line sorafenib and to develop a new prognostic score to guide management.

MATERIALS AND METHODS

Retrospective review of 145 pts bNLR, overall toxicity, early toxicity rates and overall survival (OS) were assessed. Univariate and multivariate analysis of prognostic factors for OS was performed. The prognostic score was calculated from the coefficients found in the Cox analysis. ROC curves and pseudoR2 index were used for internal validation. Discrimination ability and calibration were tested by Harrel's c-index (HCI) and Akaike criteria (AIC).

RESULTS

The optimal bNLR cut-off for the prediction of OS was 4 (AUC 0.62). Independent prognostic factors in multivariate analysis for OS were performance status (PS) (p < .0001), Child-Pugh (C-P) score (p = 0.005), early-onset diarrhoea (p = 0.006) and BNLR (0.011). The prognostic score based on these four variables was found efficient (HCI = 0.659; AIC = 1.180). Four risk groups for OS could be identified: a very low-risk (median OS = 48.6 months), a low-risk (median OS = 11.6 months), an intermediate-risk (median OS = 8.3 months) and a high-risk group (median OS = 4.4 months).

CONCLUSIONS

PS and C-P score were the main prognostic factors for OS, followed by early-onset diarrhoea and bNLR. We identified four risk groups for OS depending on these parameters. This prognostic model could be useful for patient stratification, but an external validation is needed.

Prognostic value of site-specific extra-hepatic disease in hepatocellular carcinoma: a SEER database analysis

BACKGROUND

We the prognostic value of site-specific extra-hepatic disease in hepatocellular carcinoma (HCC) patients registered within the surveillance, epidemiology and end results (SEER) database.

METHODS

SEER database (2010-2013) has been queried through SEER*Stat program to determine the prognosis of advanced HCC patients according to the site of extra-hepatic disease. Survival analysis has been conducted through Kaplan Meier analysis.

RESULTS

A total of 4396 patients with stage IV HCC were identified in the period from 2010-2013 and they were included into this analysis. Patients with isolated regional lymph node involvement have better outcomes compared to patients with any other site of extra-hepatic disease (P < 0.0001 for both endpoints). Among patients with distant metastases, patients with bone metastases have better outcomes compared to patients with lung metastases (P < 0.0001 for both endpoints). Multivariate analysis revealed that younger age, normal alpha fetoprotein, single site of extra-hepatic disease, local treatment to the primary tumor and surgery to the metastatic disease were associated with better overall survival and liver cancer-specific survival.

CONCLUSION

Within the limits of the current SEER analysis, HCC patients with isolated lung metastases seem to have worse outcomes compared to patients with isolated bone or regional nodal metastases.​.

Role of liver-directed local tumor therapy in the management of hepatocellular carcinoma with extrahepatic metastases: a SEER database analysis

BACKGROUND

This study assessed the prognostic impact of the liver-directed local tumor therapy in the management of hepatocellular carcinoma (HCC) with extrahepatic metastases.

METHODS

Metastatic HCC patients diagnosed between 2004 and 2013 were identified from the SEER (Surveillance, Epidemiology, and End Results) database. Propensity-matched analysis was performed considering baseline characteristics (age, gender, race, histology, TNM stage, site of metastases, fibrosis score and alpha fetoprotein).

RESULTS

A total of 2529 patients were identified. The median age was 65 years, and 151 patients received liver-directed local treatment (either surgical treatment or local destructive treatment). Both before and after propensity score matching, cancer-specific and overall survival (p < 0.0001 for all) were better in the liver-directed local therapy group. When the overall survival was stratified by the type of local treatment (surgical resection versus destructive treatment), both types of treatment improved overall survival (p < 0.0001 for both). In multivariate analysis of the matched population, the only factor correlated with better survival receiving is local therapy (p < 0.0001).

CONCLUSION

This analysis suggests that liver-directed local treatment may play a role -in addition to systemic treatment- in the management of selected patients with metastatic HCC. Further prospective randomized controlled trials are needed to confirm or deny this hypothesis.