Sintilimab plus a bevacizumab biosimilar (IBI305) versus sorafenib in unresectable hepatocellular carcinoma (ORIENT-32): a randomised, open-label, phase 2-3 study

Drug resistance in TKI therapy for hepatocellular carcinoma: Mechanisms and strategies

Tyrosine kinase inhibitors (TKIs) are such as sorafenib the first-line therapeutic drugs for patients with advanced hepatocellular carcinoma. However, patients with TKI-resistant advanced liver cancer are insensitive to TKI treatment, resulting in limited survival benefits. This paper comprehensively reviewed the mechanisms underlying TKI resistance in hepatocytes, investigating activation of tumor signaling pathways, epigenetic regulation, tumor microenvironment, and metabolic reprogramming. Based on resistance mechanisms, it also reviews preclinical and clinical studies of drug resistance strategies and summarizes targeted therapy combined with immunotherapy currently in investigational clinical trials. Understanding the interactions and clinical studies of these resistance mechanisms offers new hope for improving and prolonging patient survival.

Neoadjuvant therapy: Dawn of reducing the high post-surgery recurrence rate of hepatocellular carcinoma

The high postoperative recurrence rate remains a major challenge in the treatment of hepatocellular carcinoma (HCC) following resection. Increasing research has been delved into investigating the role of neoadjuvant therapy on the prognosis of resectable HCC. Recent trends in combination therapy with molecularly targeted agents and immune checkpoint inhibitors have significantly improved the efficacy of systemic antitumor treatments, yielding survival benefits exceeding 40%. Neoadjuvant therapy for HCC, whether based on systemic antitumor treatments, locoregional therapies, or their combination, has emerged as a promising research direction. However, there remains a matter of debate on neoadjuvant therapy. In this review, we summarize and discuss the research progress and challenges of neoadjuvant therapy for HCC over the past five years from the perspective of Chinese guidelines to provide new insights and future directions in this field.

Neoadjuvant immune checkpoint inhibitors for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of liver cancer. HCC treatment is challenging; surgical resection is the primary curative treatment for early-stage disease, but recurrence rates are high. Immune checkpoint inhibitors (ICIs) are a promising neoadjuvant treatment that can reduce recurrence rates and mortality after surgery and achieve complete/partial responses. Clinical trials provide strong evidence for the efficacy and safety of ICI monotherapy for neoadjuvant HCC treatment.

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).

Cytochrome P450 2E1 inhibitor Q11 is effective on hepatocellular carcinoma by promoting peritumor neutrophil chemotaxis

Current studies found that the peritumoral tissue of hepatocellular carcinoma (HCC) may be different from normal liver tissue based on proteomics, and related to progression, recurrence and metastasis of HCC. Our previous study proposed "peritumor microenvironment (PME)" to summarize the influence of peritumor tissue on occurrence and progression of HCC. Peritumor CYP2E1 activity was significantly elevated in HCC, and related to occurrence and progression of HCC. However, the effectiveness and mechanism of inhibiting CYP2E1 against HCC remain unclear. In this study, by integrating the advantages of proteomics and transcriptomics, we reanalyzed the various influencing factors in PME. Although there were large differences in the occurrence and progression, the immunity and inflammation still played crucial roles. Peritumor neutrophil were "pro-tumor" phenotype in the stage of progression, while it showed cytotoxicity for tumor cell in the occurrence stage. CYP2E1 activity is associated with peritumor neutrophil infiltration and occurrence of HCC. CYP2E1 inhibitor Q11 showed anti-tumor effects in an orthotopic HCC mouse model by promoting secretion of chemokines and infiltration of neutrophils in peritumor tissue. Overall, these findings provided a reasonable mechanism of anti-tumor effects of CYP2E1 inhibitors, which may be a new strategy for the prevention and treatment of HCC.

Immunosenescence and immunotherapy in elderly patients with hepatocellular carcinoma

Liver cancer, more specifically hepatocellular carcinoma (HCC), is a global health issue and one of the dominant causes of cancer death around the world. In the past few decades, remarkable advances have been achieved in the systemic therapy of HCC. Immune checkpoint inhibitors (ICIs) have become a therapy mainstay for advanced HCC and have shown promise in the neoadjuvant therapy before resection. Despite these significant advancements, the compositions and functions of the immune system occur various alterations with age, called "immunosenescence", which may affect the antitumor effects and safety of ICIs, thus raising concerns that immunosenescence may impair elderly patients' response to ICIs. Therefore, it is important to learn more about the immunosenescence characteristics of elderly patients. However, the real-world elderly HCC patients may be not accurately represented by the elderly patients included in the clinical trials, affecting the generalizability of the efficacy and safety profiles from the clinical trials to the real-world elderly patients. This review summarizes the characteristics of immunosenescence and its influence on HCC progression and immunotherapy efficacy as well as provides the latest progress in ICIs available for HCC and discusses their treatment efficacy and safety on elderly patients. In the future, more studies are needed to clarify the mechanisms of immunosenescence in HCC, and to find sensitive screening tools or biomarkers to identify the patients who may benefit from ICIs.

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.

Programmed cell death 1 inhibitor sintilimab plus S-1 and gemcitabine for liver metastatic pancreatic ductal adenocarcinoma

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is a highly aggressive cancer with poor prognosis. When it metastasizes to the liver, treatment options become particularly limited and challenging. Current treatment options for liver metastatic PDAC are limited, and chemotherapy alone often proves insufficient. Immunotherapy, particularly programmed cell death 1 (PD-1) inhibitors like sintilimab, shows potential efficacy for various cancers but has limited reports on PDAC. This study compares the efficacy and safety of sintilimab plus S-1 and gemcitabine vs S-1 and gemcitabine alone in liver metastatic PDAC.

AIM

To explore the feasibility and effectiveness of combined PD-1 inhibitor sintilimab and S-1 and gemcitabine (combination group) vs S-1 and gemcitabine used alone (chemotherapy group) for treating liver metastatic pancreatic adenocarcinoma.

METHODS

Eligible patients were those with only liver metastatic PDAC, an Eastern Cooperative Oncology Group performance status of 0-1, adequate organ and marrow functions, and no prior anticancer therapy. Participants in the combination group received intravenous sintilimab 200 mg every 3 weeks, oral S-1 40 mg/m² twice daily on days 1-14 of a 21-day cycle, and intravenous gemcitabine 1000 mg/m² on days 1 and 8 of the same cycle for up to eight cycles or until disease progression, death, or unacceptable toxicity. Participants in the chemotherapy group received oral S-1 40 mg/m² twice daily on days 1-14 of a 21-day cycle and intravenous gemcitabine 1000 mg/m² on days 1 and 8 of the same cycle for up to eight cycles. Between June 2020 and December 2021, 66 participants were enrolled, with 32 receiving the combination treatment and 34 receiving chemotherapy alone.

RESULTS

The group receiving the combined therapy exhibited a markedly prolonged median overall survival (18.8 months compared to 10.3 months, P < 0.05) and progression-free survival (9.6 months vs 5.4 months, P < 0.05). compared to the chemotherapy group. The incidence of severe adverse events did not differ significantly between the two groups (P > 0.05).

CONCLUSION

The combination of PD-1 inhibitor sintilimab with S-1 and gemcitabine demonstrated effectiveness and safety for treating liver metastatic PDAC, meriting further investigation.

Combination locoregional and systemic therapies in hepatocellular carcinoma

Locoregional therapies play a fundamental role in the treatment of patients with early and intermediate and locally advanced hepatocellular carcinomas. With encouraging recent advances in immunotherapy-based systemic therapies, locoregional therapies are being both promoted and challenged by new systemic therapy options. Combined locoregional and systemic therapies might enhance treatment outcomes compared with either option alone. This Series paper summarises the existing data on locoregional and systemic therapies for hepatocellular carcinoma, and discusses evidence from studies investigating their combination with a focus on their synergistic efficacy and safety.

Combining immune checkpoint inhibitors and molecular-targeted agents with hepatic arterial infusion chemotherapy for hepatocellular carcinoma with inferior vena cava and/or right atrium tumor thrombus

BACKGROUND

Hepatocellular carcinoma with inferior vena cava and/or right atrium tumor thrombus (HCC-IVC/RATT) has a poor prognosis and lacks evidence for standard first-line systemic therapy. This study aims to evaluate the effectiveness and safety of three therapeutic regimens in HCC-IVC/RATT: immune checkpoint inhibitors plus molecular-targeted agents (ICI-MTA), hepatic arterial infusion chemotherapy (HAIC), and their combination (ICI-MTA-HAIC).

METHODS

This multicenter retrospective cohort study included consecutive HCC-IVC/RATT who received ICI-MTA-HAIC, ICI-MTA, or HAIC from June 2015 to December 2023. Propensity score matching (PSM) was used to balance baseline characteristics.

RESULTS

A total of 355 patients were included: 209 received ICI-MTA-HAIC, 66 received ICI-MTA, and 80 received HAIC. After PSM, the ICI-MTA-HAIC group showed superior median overall survival (OS) to both the ICI-MTA (18.0 vs. 7.5 months, p < 0.001) and HAIC (18.5 vs. 7.1 months, p < 0.001) groups. The ICI-MTA-HAIC group demonstrated better median progression-free survival (PFS) and objective response rate (ORR) compared to the ICI-MTA (PFS: 9.5 vs. 4.4 months; ORR: 47.0% vs. 21.3%, all p < 0.001) and HAIC (PFS: 9.5 vs. 4.4 months; ORR: 48.8% vs. 21.6%, all p < 0.001) groups. There was no significant difference in OS, PFS, or ORR between the ICI-MTA and HAIC groups (all p > 0.05). Grade 3-4 adverse event rates were 49.8%, 33.3%, and 35.0% for the ICI-MTA-HAIC, ICI-MTA, and HAIC groups, respectively. No unexpected events or treatment-related deaths were observed.

CONCLUSION

ICI-MTA-HAIC was a safe and effective therapy that prolonged the survival of HCC-IVC/RATT compared to ICI-MTA or HAIC.

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.

The anti-PD-L1/CTLA-4 bispecific antibody KN046 plus lenvatinib in advanced unresectable or metastatic hepatocellular carcinoma: a phase II trial

This open-label phase II trial (NCT04542837) aimed to evaluate the efficacy and safety of KN046 combined with lenvatinib in patients with advanced hepatocellular carcinoma (HCC), and explore the potential response biomarkers. Participants received KN046 5 mg/kg every 3 weeks and lenvatinib 12 or 8 mg once daily. The primary endpoints were safety, tolerability, dose-limiting toxicity (DLT), and objective response rate (ORR) according to RECIST v1.1. A total of fifty-five participants were enrolled. The results meet the pre-specified primary endpoints. No DLT was observed in the safety run-in period. The incidence of serious adverse events and grade ≥3 treatment-related adverse events (TRAEs) was 30.9% and 47.3%, respectively. Grade ≥3 immunotherapy-related adverse events occurred in 3 (5.5%) participants. Five (9.1%) participants discontinued treatment due to TRAEs, all of which were grade 1-2. The ORR was 45.5% (95% CI, 31.97-59.45). The median progression-free survival was 11.0 (95% CI, 8.21-15.24) months. The median overall survival (OS) was 16.4 (95% CI, 11.20-not estimable) months, and 12-month OS rate was 60.0% (95% CI, 45.87-71.55). Circulating tumor DNA status before the third cycle of treatment was associated with prognosis. In conclusion, First-line KN046 plus lenvatinib shows promising efficacy for advanced unresectable or metastatic HCC.

Immunotherapy improved the efficacy of TACE or TACE plus MTTs in HCC patients: A meta-analysis

BACKGROUND

Although several studies have compared the efficacy and safety of transarterial chemoembolization (TACE) without immune checkpoint inhibitors (ICIs) and TACE with ICIs, there is still a lack of meta-analysis.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched until July 2023 for studies comparing the efficacy and safety of TACE without ICIs (TACE ± molecular targeted therapies [MTTs]) and TACE without ICIs (TACE ± MTTs + ICIs). Outcomes included overall survival (OS), progression-free survival (PFS), objective response rate (ORR), disease control rate (DCR), and adverse events (AEs).

RESULTS

A total of 20 studies involving 2587 HCC patients were included in the meta-analysis. Eighteen studies including 2116 patients looked at the difference in OS between TACE ± MTTs or TACE ± MTTs + ICIs. Compared with TACE ± MTTs, TACE ± MTTs + ICIs were associated with significantly improved OS (HR, 0.37; 95 % CI, 0.30-0.46). Thirteen studies including 1650 patients investigated the difference in PFS between TACE ± MTTs or TACE ± MTTs + ICIs. The outcome showed that TACE ± MTTs + ICIs were associated with longer PFS (HR, 0.50; 95 % CI, 0.41-0.61, P < 0.001). Eighteen studies including 1971 patients investigated the difference in tumor response (ORR and DCR) between TACE ± MTTs or TACE ± MTTs + ICIs. The outcomes indicated that TACE ± MTTs + ICIs bring higher ORR and DCR compared to TACE ± MTTs (ORR: OR, 2.39; 95 % CI, 1.97-2.89, P < 0.001; DCR: OR, 2.30; 95 % CI, 1.84-2.88). Moreover, to look at the direct impact of ICIs, we investigated the difference in OS, PFS, ORR, DCR, AEs, and severe AEs between TACE + tyrosine kinase inhibitors (TKIs) and TACE + TKIs + ICIs. The results indicated that the addition of ICIs provided longer OS, longer PFS, higher ORR, and higher DCR, but did not bring additional AEs and severe AEs.

CONCLUSION

Immune checkpoint inhibitors improved the efficacy of TACE or TACE plus MTTs and prolonged the survival of patients with hepatocellular carcinoma. Meanwhile, the addition of immune checkpoint inhibitors to the TACE + TKIs did not bring additional adverse events.

Radiotherapy with targeted and immunotherapy improved overall survival and progression-free survival for hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND

The efficacy of radiotherapy (RT) combined with targeted therapy and immunotherapy in treating hepatocellular carcinoma (HCC) and portal vein tumor thrombosis (PVTT) is still unclear. This study investigated the efficacy and safety of RT combined with targeted therapy and immunotherapy in HCC with PVTT.

MATERIALS AND METHODS

Seventy-two patients with HCC with PVTT treated with tyrosine kinase inhibitor (TKI) plus programmed cell death protein-1 (PD-1) inhibitor with or without RT from December 2019 to December 2023 were included. After propensity score matching (PSM) for adjusting baseline differences, 32 pairs were identified in RT + TKI + PD-1 group (n = 32) and TKI + PD-1 group (n = 32). Primary endpoints were overall survival (OS) and progression-free survival (PFS). Secondary endpoints included objective response rate (ORR), disease control rate (DCR), and treatment-related adverse events (TRAEs).

RESULTS

Median OS (mOS) in RT + TKI + PD-1 group was significantly longer than TKI + PD-1 group (15.6 vs. 8.2 months, P = .008). Median PFS (mPFS) in RT + TKI + PD-1 group was dramatically longer than TKI + PD-1 group (8.1 vs. 5.2 months, P = .011). Patients in TKI + PD-1 + RT group showed favorable ORR and DCR compared with TKI + PD-1 group (78.1% vs. 56.3%, P = .055; 93.8% vs. 81.3%, P = .128). Subgroup analysis demonstrated a remarkable OS and PFS benefit with TKI + PD-1 + RT for patients with main PVTT (type III/IV) and those of Child-Pugh class A. Multivariate analysis confirmed RT + TKI + PD-1 as an independent prognostic factor for longer OS (HR 0.391, P = .024) and longer PFS (HR 0.487, P = .013), with no mortality or severe TRAEs.

CONCLUSION

RT combined with TKI and PD-1 inhibitor could significantly improve mOS and mPFS without inducing severe TRAEs or mortality.

Donafenib combined with sintilimab for advanced hepatocellular carcinoma: a single arm phase II trial

BACKGROUND

Previous studies evaluating antiangiogenic agents plus immune checkpoint inhibitors for unresectable hepatocellular carcinoma (HCC) have shown encouraging results. This study was conducted to investigate the efficacy and safety of donafenib combined with sintilimab (Don-Sin) for advanced HCC.

METHODS

This was a single-center, single-arm phase II trial recruiting patients with BCLC stage C HCC. A safety run-in cohort was planned with the first 6 patients receiving oral donafenib 200 mg twice daily and intravenous sintilimab 200 mg once every 3 weeks. Dose-limiting toxicities (DLTs) were evaluated to determine the recommended dose of donafenib for those enrolled thereafter. The primary endpoint of this study was progression-free survival (PFS) per mRECIST.

RESULTS

30 patients were enrolled. As 3 patients (50.0%) experienced DLTs during safety run-in, the initial dose of donafenib was adjusted to 200 mg once daily for subsequent patients. The primary endpoint was met with a median PFS of 6.2 (95% confidence interval [CI], 4.4-8.0) months per mRECIST (6.3 [95% CI, 5.4-7.2] months per RECIST 1.1). The objective response rate was 23.3% per mRECIST and 16.7% per RECIST 1.1, while the disease control rate reached 76.7% per mRECIST/RECIST 1.1. The median overall survival was 16.0 (95% CI, 13.5-18.5) months. Treatment-related adverse events (TRAEs) occurred in 28 patients (93.3%) and grade 3 TRAEs were observed in 9 patients (30.0%).

CONCLUSIONS

Don-Sin showed promising antitumor effects with an acceptable safety profile in patients with advanced stage HCC. The preliminary findings need to be further evaluated in phase III randomized controlled trials.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier: NCT05162352; date of registration: December 4, 2021).

Systemic therapy for hepatocellular carcinoma, from the early to the advanced stage: a Japanese perspective

Systemic therapy has now become mainstream for the treatment of hepatocellular carcinoma (HCC) and is also changing from molecular-targeted therapy, such as with sorafenib and lenvatinib, to immunotherapy, such as with the atezolizumab plus bevacizumab and durvalumab plus tremelimumab combination regimens. Molecular-targeted therapy is selected as the first-line treatment when immunotherapy is not indicated or as second- or later-line treatment when immunotherapy is ineffective. It is necessary to select the appropriate treatment taking into consideration the expected treatment efficacy and adverse events, as well as the hepatic reserve. Currently, newer agents and combination regimens as first-line/second-line treatment for advanced-stage HCC, combined therapy with transarterial chemoembolization for intermediate-stage HCC, and perioperative adjuvant therapy for curative treatment for early-stage HCC are being developed. Therefore, systemic therapy is now indicated for any stage of the disease. While local therapies were previously used as the main treatment strategy for HCC, systemic therapy in combination with local therapies is being actively attempted at present. Systemic therapy is currently the main focus of development of novel treatments 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.

Health-related quality of life and symptoms in patients with previously untreated, locally advanced or metastatic non-squamous non-small cell lung cancer treated with sintilimab or placebo plus pemetrexed and platinum (ORIENT-11): A randomized, double-blind, phase 3 trial

BACKGROUND

In the phase 3 ORIENT-11 study, sintilimab plus pemetrexed-platinum provided statistically significant longer overall survival and progression-free survival versus placebo plus pemetrexed-platinum as first-line treatment in patients with locally advanced or metastatic non-squamous non-small cell lung cancer (NSCLC). Here, we report the patient-reported outcomes (PRO) analysis findings in ORIENT-11.

METHODS

PROs were measured using the European Organization for Research and Treatment of Cancer Quality of Life of Cancer Patients Questionnaire Core 30 items (EORTC QLQ-C30) and the Lung Cancer Symptom Scale (LCSS) questionnaire. PRO endpoints included evaluation of least square (LS) mean changes from baseline to week 12 (platinum-containing treatment) and week 21 (maintenance treatment), time to true deterioration (TTD), and overall improvement or stability rate for QLQ-C30 and LCSS scales. PRO scores in two groups were compared using the Mann-Whitney test. Least squares (LS) mean changes from baseline to week 12, week 21, and other time points were assessed with mixed-effect model repeated measures analysis. TTD was calculated using the Kaplan-Meier method and compared with the Cox proportional hazards model between groups.

RESULTS

252 (94.7 %) patients in the sintilimab-combination group and 123 (93.9 %) patients in the placebo-combination group had a baseline and at least one postbaseline PRO assessment. Change from baseline to week 12 or 21 favored the sintilimab-combination group on QLQ-C30 global health status/quality of life (GHS/QoL), most function and symptoms scales, and most LCSS scales. Notably, the QLQ-C30 pain score change gradually deteriorated in the placebo-combination group with increased treatment. At the same time, it improved in the sintilimab-combination group significantly from 6 weeks later, with the improvement sustained in subsequent courses of treatment. Sintilimab plus chemotherapy significantly delayed the TTD in most QLQ-C30 and LCSS scales compared with placebo plus chemotherapy, and the overall improvement or stability rates were higher in the former.

CONCLUSIONS

The addition of sintilimab to chemotherapy maintained or improved health-related quality of life and symptoms compared with chemotherapy. Along with the previous efficacy and safety results, these data support the addition of sintilimab to standard chemotherapy as first-line therapy in locally advanced or metastatic non-squamous NSCLC.

CLINICAL TRIAL REGISTRATION

NCT03607539.

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.

Role of immunotherapy in managing cancers prior to liver transplantation

PURPOSE OF REVIEW

Immune checkpoint inhibitors (ICIs) have transformed the treatment landscape in advanced hepatocellular carcinoma and increasingly are being evaluated in earlier stage disease. Herein we explore the role of ICIs pre-liver transplant for liver cancers.

RECENT FINDINGS

Given the high response rates with combination approaches including locoregional treatments, more patients with liver confined disease, without vascular invasion, who have received ICIs are now being rendered eligible for potential liver transplant. This opportunity to expand the population who may benefit from liver transplant has also come with challenges recognizing the global shortage of organs. Post-liver transplant immunosuppression potentially competes with the immune-stimulating effects of ICIs and graft rejection has been a concern. ICIs may provide an opportunity to maintain patients on the waiting list but an understanding of who is likely to benefit is needed, to circumvent possible toxicities. In addition, ICIs are now considered standard of care, in combination with chemotherapy, for advanced cholangiocarcinoma, where the role of liver transplant is evolving.

SUMMARY

As the eligibility criteria globally for liver transplant in the setting of malignancy continues to expand, the integration of ICIs becomes increasingly important.

Advancements in immunotherapy for hepatocellular carcinoma

INTRODUCTION

The advent of immune-based combinations, primarily leveraging immune checkpoint inhibitors, has revolutionized the therapeutic landscape of hepatocellular carcinoma (HCC). The current scenario features multiple therapies that have shown superiority over tyrosine kinase inhibitors; however, the absence of direct comparisons and validated prognostic biomarkers complicates therapeutic decision-making. Additionally, a significant proportion of patients still exhibit primary or secondary resistance to existing immunotherapies, underscoring the ongoing need for novel therapeutic strategies.

AREAS COVERED

This narrative review discusses current strategies aimed at improving the efficacy of immunotherapy for HCC, focusing on the following aspects: available therapeutic options, identification of prognostic biomarkers, approaches to overcoming resistance (including the development of neoantigen vaccines), and the exploration of adjuvant and neoadjuvant strategies.

EXPERT OPINION

The future of systemic therapies for HCC is likely to be driven by advancements in immunotherapy. Key areas of exploration for the coming years include the discovery of novel checkpoint inhibitors or complementary agents to enhance tumor response when combined with existing treatments, a shift toward neoadjuvant/perioperative trials instead of traditional adjuvant approaches, and the development of personalized neoantigen vaccines.

T-cell Receptor Repertoire Analysis in the Context of Transarterial Chemoembolization Synergy with Systemic Therapy for Hepatocellular Carcinoma

T-cell receptor (TCR) sequencing provides a novel platform for insight into and characterization of intricate T-cell profiles, advancing the understanding of tumor immune heterogeneity. Recently, transarterial chemoembolization (TACE) combined with systemic therapy has become the recommended regimen for advanced hepatocellular carcinoma. The regulation of the immune microenvironment after TACE and its impact on tumor progression and recurrence has been a focus of research. By examining and tracking fluctuations in the TCR repertoire following combination treatment, novel perspectives on the modulation of the tumor microenvironment post-TACE and the underlying mechanisms governing tumor progression and recurrence can be gained. Clarifying the distinctive metrics and dynamic alterations of the TCR repertoire within the context of combination therapy is imperative for understanding the mechanisms of anti-tumor immunity, assessing efficacy, exploiting novel treatments, and further advancing precision oncology in the treatment of hepatocellular carcinoma. In this review, we initially summarized the fundamental characteristics of TCR repertoire and depicted immune microenvironment remodeling after TACE. Ultimately, we illustrated the prospective applications of TCR repertoires in TACE combined with systemic therapy.

Clinical Outcomes of Hepatic Arterial Infusion Chemotherapy Plus Lenvatinib and Tislelizumab for Treating Hepatocellular Carcinoma and Type IV Portal Vein Tumor Thrombus

Purpose

To assess the activity and toxicity of hepatic arterial infusion chemotherapy (HAIC)+tislelizumab+lenvatinib (HAIC+tisle+len) in hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) type IV (Vp4 hCC) in a real-world context.

Methods

Fifty-five patients, with Vp4 hCC receiving HAIC+tisle+len therapy from April 2021 to December 2022, were analyzed retrospectively. Data on patient characteristics, adverse events (AEs), treatment, and survival were collected. Outcomes were disease control rate (DCR), overall response rate (ORR), overall survival (OS), progression-free survival (PFS), and treatment-related AEs (TRAEs).

Results

As of December 20, 2023, the median follow-up was 17.5 months (95% confidence interval [CI]: 14.7-22.5). The ORR was 52.7% (3 complete response [CR], 26 partial response [PR]) as per RECIST v1.1 and 65.5% (12 CR, 24 PR) as per mRECIST. The DCR was 94.5% using both RECIST v1.1 and mRECIST. The median PFS and the median OS were 8.0 months (95% CI: 6.2-12.3) and 16.7 months (95% CI: 12.0-not reached), respectively. Additionally, PFS was independently predicted only by the best tumor response. In patients with the best tumor response (PR or CR), the median PFS was 11.7 months (95% CI: 8.02-not reached) by mRECIST and 15.4 months (95% CI: 7.39-not reached) by RECIST v1.1. Hypertension (14.5%), decreased albumin levels (10.9%) and anorexia (9.1%) were the most frequently observed grade 3-4 TRAEs.

Conclusion

HAIC+tisle+len regimen demonstrated a promising efficacy and favorable safety for patients with HCC and Vp4, providing valuable real-world evidence to complement the trial data for Vp4 hCC.

The Prognostic Value of Peripheral Blood Inflammatory Markers in Hepatocellular Carcinoma Treated with Lenvatinib Combined with PD-1 Inhibitors

Purpose

To investigate the prognostic value of inflammatory indexes based on peripheral blood cells in unresectable hepatocellular carcinoma (HCC) patients treated with Lenvatinib combined with PD-1 inhibitors.

Methods

This study retrospectively collected baseline inflammatory indexes from HCC patients received Lenvatinib and PD-1 inhibitor-based combination therapy at the Cancer Hospital of the Chinese Academy of Medical Sciences between October 2018 and October 2021. The optimal threshold values for inflammatory indexes determined using X-tile. The factors related to treatment response and survival outcomes were analyzed through logistic regression and Cox regression, respectively. A novel preoperative prognostic nomogram was constructed based on inflammatory indexes, and the predictive efficacy of the nomogram and BCLC staging was compared by the area under the ROC curve.

Results

156 eligible patients with unresectable HCC were included, with median OS and PFS of 23.8 and 11.5 months, respectively, and ORR of 48.7%. The baseline SIRI was an independent factor of treatment response, with a significantly higher ORR for patients with a SIRI <0.8 than for patients with a SIRI ≥0.8 (59.7% vs 41.5%, P=0.03). SIRI and PNI were independent prognostic factors of PFS, and SIRI was an independent prognostic factor of OS. The AUC value of nomogram based on baseline SIRI, PNI, and tumor distribution in predicting the 6-,12- and 18-month PFS of patients was significantly higher than that of traditional BCLC stage, and its prediction performance was substantially better than that of BCLC stage system (C-index, 0.730 vs 0.535).

Conclusion

The baseline SIRI could be used as a potential non-invasive biomarker to predict the efficacy and survival benefit of immune combination therapy for HCC. The nomogram based on inflammation indexes could achieve better prediction performance and help clinicians to identify high-risk patients and formulate treatment plans.

Multiplex immunohistochemistry to explore the tumor immune microenvironment in HCC patients with different GPC3 expression

OBJECTIVES

GPC3 has been recognized as a promising target for immunotherapy in hepatocellular carcinoma (HCC). However, the GPC3-targeted immunotherapies have shown limited therapeutic efficacy. The use of anti-PD-1/PD-L1 monoclonal antibodies in HCC treatment is considerably constrained. Furthermore, there is still a notable lack of understanding concerning the immune landscape in HCC, especially regarding varied GPC3 expression levels. Therefore, thorough exploration of the intricate tumor immune microenvironment at different GPC3 expression levels is essential for guiding and improving HCC treatment strategies.

METHODS

Sixty patients with HCC were enrolled in this study, receiving a first-line treatment that combined anti-angiogenesis targeted drugs and immunotherapy. Immunohistochemistry was used to assess the levels of GPC3 expression. Multiple immunohistochemical markers, such as CD8, PD-1, LAG3, TIGIT, TIM-3, CD103, Claudin18.2, PD-L1, CD4, Foxp3, CD68, CD163, GPC3, CD11C, CD14, CD66b, and HLA-DR, were used to characterize the immune microenvironment and spatial distribution of immune cells in HCC tumors with different levels of GPC3 expression. Cell expression levels and spatial distribution were determined by fluorescence staining and subsequent analysis of fluorescence intensity using the Panoramic Pathology Workstation (Pano ATLAS). This approach facilitated a detailed examination of cell characteristics and spatial information within the samples.

RESULTS

Based on the result of GPC3 immunohistochemical analysis, patients with strong positive GPC3 expression were classified as high GPC3 expression, while the others were classified as low GPC3 expression. Patients in the low GPC3 expression group had longer overall survival (OS) than in the high group (P = 0.003, HR = 2.9240). Further exploration of the immune microenvironment based on different GPC3 expression levels revealed that in high GPC3 expression group, the proportions of CD8+ T cells(P = 0.0435), TIM-3+ T cells(P = 0.0447), CD103+CD8+ tissue-resident T cells(P = 0.0410), CD11C+CD14-DC cells(P = 0.0497), CD11C+HLA-DR-DC cells(P = 0.0309), CD11C+CD14-HLA-DR-DC cells(P = 0.0233), and CD11C+CD14-CD66b-DC cells(P = 0.0474) were all higher compared to low expression group. At spatial distances of 10 μm, 20 μm, and 30 μm, the levels of CD8+ T cells were higher in the high expression group compared to the low expression group (high vs. low: P = 0.0281, P = 0.0236, P = 0.0220).

CONCLUSIONS

Multiple immunohistochemistry is a powerful technique for exploring the intricate immune microenvironment of hepatocellular carcinoma, enabling the precise identification of diverse cell subsets and their spatial distribution within the tumor microenvironment. This methodology provides valuable insights into the complex interactions and spatial organization of immune cells in the context of hepatocellular carcinoma progression. Low GPC3 expression in HCC patients indicates potential benefits from combined targeted and immunotherapy. Different levels of GPC3 expression levels can predict the effectiveness of targeted combination immunotherapy in HCC patients. Additionally, different GPC3 expression patterns in HCC patients correspond to unique tumor immune microenvironments, which have implications for guiding HCC treatment approaches.

Durvalumab with or without bevacizumab with transarterial chemoembolisation in hepatocellular carcinoma (EMERALD-1): a multiregional, randomised, double-blind, placebo-controlled, phase 3 study

BACKGROUND

Transarterial chemoembolisation (TACE) is standard of care for patients with unresectable hepatocellular carcinoma that is amenable to embolisation; however, median progression-free survival is still approximately 7 months. We aimed to assess whether adding durvalumab, with or without bevacizumab, might improve progression-free survival.

METHODS

In this multiregional, randomised, double-blind, placebo-controlled, phase 3 study (EMERALD-1), adults aged 18 years or older with unresectable hepatocellular carcinoma amenable to embolisation, an Eastern Cooperative Oncology Group performance status of 0 or 1 at enrolment, and at least one measurable intrahepatic lesion per modified Response Evaluation Criteria in Solid Tumours (RECIST) were enrolled at 157 medical sites including research centres and general and specialist hospitals in 18 countries. Eligible patients were randomly assigned (1:1:1), stratified by TACE method, region, and portal vein invasion, using an interactive voice response or web response system, to TACE plus either durvalumab plus bevacizumab (1500 mg intravenous durvalumab once every 4 weeks, then 1120 mg durvalumab plus 15 mg/kg intravenous bevacizumab once every 3 weeks), durvalumab plus placebo (same regimen using placebo instead of bevacizumab), or placebo alone (same regimen using placebo instead of durvalumab and instead of bevacizumab). Participants, investigators, and those assessing outcomes were masked to treatment assignment until data analysis. The primary endpoint was progression-free survival, by blinded independent central review (BICR), and per RECIST version 1.1, with durvalumab plus bevacizumab versus placebo alone in the intention-to-treat population (ITT; ie, all participants assigned to treatment). Key secondary endpoints were progression-free survival by BICR per RECIST version 1.1 with durvalumab plus placebo versus placebo alone, overall survival, and time to deterioration in select patient-reported outcomes. Participants continue to be followed up for overall survival, and overall survival and patient-reported outcomes will be reported in a later publication. Safety was assessed in the safety analysis set, which included all participants assigned to treatment who received any study treatment (ie, any durvalumab, bevacizumab, or placebo) by treatment received. This study is registered with ClinicalTrials.gov, NCT03778957, and is closed to accrual.

FINDINGS

Between Nov 30, 2018, and July 19, 2021, 887 patients were screened, of whom 616 were randomly assigned to durvalumab plus bevacizumab (n=204), durvalumab plus placebo (n=207), or placebo alone (n=205; ITT population). Median age was 65·0 years (IQR 59·0-72·0), 135 (22%) of 616 participants were female, 481 (78%) were male, 375 (61%) were Asian, 176 (29%) were White, 22 (4%) were American Indian or Alaska Native, nine (1%) were Black or African American, one (<1%) was native Hawaiian or other Pacific Islander, and 33 (5%) were other races. As of data cutoff (Sept 11, 2023) median follow-up for progression-free survival was 27·9 months (95% CI 27·4-30·4), median progression-free survival was 15·0 months (95% CI 11·1-18·9) with durvalumab plus bevacizumab, 10·0 months (9·0-12·7) with durvalumab, and 8·2 months (6·9-11·1) with placebo. Progression-free survival hazard ratio was 0·77 (95% CI 0·61-0·98; two-sided p=0·032) for durvalumab plus bevacizumab versus placebo, and 0·94 (0·75-1·19; two-sided p=0·64) for durvalumab plus placebo versus placebo. The most common maximum grade 3-4 adverse events were hypertension in participants who received durvalumab and bevacizumab (nine [6%] of 154 participants), anaemia in participants who received durvalumab and placebo (ten [4%] of 232 participants), and post-embolisation syndrome in participants who received placebo alone (eight [4%] of 200 participants). Study treatment-related adverse events that led to death occurred in none of 154 participants who received durvalumab and bevacizumab, three (1%) of 232 who received durvalumab and placebo (n=1 for arterial haemorrhage, liver injury, and multiple organ dysfunction syndrome), and three (2%) of 200 who received placebo alone (n=1 for oesophageal varices haemorrhage, upper gastrointestinal haemorrhage, and dermatomyositis).

INTERPRETATION

Durvalumab plus bevacizumab plus TACE has the potential to set a new standard of care. With additional follow-up of the EMERALD-1 study, future analyses, including the final overall survival data and patient-reported outcomes, will help to further characterise the potential clinical benefits of durvalumab plus bevacizumab plus TACE in hepatocellular carcinoma amenable to embolisation.

FUNDING

AstraZeneca.

Intratumoral Collagen Deposition Supports Angiogenesis Suggesting Anti-angiogenic Therapy in Armored and Cold Tumors

A previous study classifies solid tumors based on collagen deposition and immune infiltration abundance, identifying a refractory subtype termed armored & cold tumors, characterized by elevated collagen deposition and diminished immune infiltration. Beyond its impact on immune infiltration, collagen deposition also influences tumor angiogenesis. This study systematically analyzes the association between immuno-collagenic subtypes and angiogenesis across diverse cancer types. As a result, armored & cold tumors exhibit the highest angiogenic activity in lung adenocarcinoma (LUAD). Single-cell and spatial transcriptomics reveal close interactions and spatial co-localization of fibroblasts and endothelial cells. In vitro experiments demonstrate that collagen stimulates tumor cells to express vascular endothelial growth factor A (VEGFA) and directly enhances vessel formation and endothelial cell proliferation through sex determining region Y box 18 (SOX18) upregulation. Collagen inhibition via multiple approaches effectively suppresses tumor angiogenesis in vivo. In addition, armored & cold tumors display superior responsiveness to anti-angiogenic therapy in advanced LUAD cohorts. Post-immunotherapy resistance, the transformation into armored & cold tumors emerges as a potential biomarker for selecting anti-angiogenic therapy. In summary, collagen deposition is shown to drive angiogenesis across various cancers, providing a novel and actionable framework to refine therapeutic strategies combining chemotherapy with anti-angiogenic treatments.

Cirrhosis and complications hepatocellular carcinoma - expanding indications for immunotherapy

The incidence of hepatocellular carcinoma (HCC) is rising, with a shift towards Metabolic Dysfunction-associated Steatotic Liver Disease becoming the dominant risk factor in Western countries. Significant advances in treatment have broadened the range of available therapeutic options. For this reason, clinical decision-making, along with a multidisciplinary team approach, plays a crucial role in improving patient outcomes. Following several landmark trials, immune checkpoint inhibitor-based therapy has now become the established first-line standard of care for advanced HCC. Additionally, the application of immunotherapy is shifting to include patients with earlier stages of HCC. Research on the combination with locoregional therapies for intermediate-stage HCC has recently reported positive results, and other phase III trials in the same patient population and early-stage HCC are currently in progress. Furthermore, a growing number of reports support the safety and efficacy of immunotherapeutic agents as potential adjuncts for downstaging of HCC, thus facilitating successful liver transplantation. We will discuss the published and ongoing trials in the expanding field of immune checkpoint inhibitor-based therapy for different stages of HCC.

Multicenter, retrospective GUIDANCE001 study comparing transarterial chemoembolization with or without tyrosine kinase and immune checkpoint inhibitors as conversion therapy to treat unresectable hepatocellular carcinoma: Survival benefit in intermediate or advanced, but not early, stages

BACKGROUND AND AIMS

Various conversion therapy options have become available to patients with unresectable HCC, but which conversion therapy is optimal for which type of patient is controversial. This study compared the efficacy and safety of TACE alone or combined with immune checkpoint and tyrosine kinase inhibitors.

APPROACH AND RESULTS

Data were retrospectively compared for patients with initially unresectable HCC who underwent conversion therapy consisting of TACE alone (n=459) or combined with immune checkpoint and tyrosine kinase inhibitors (n=343). Compared to the group that received TACE alone, the group that received triple conversion therapy showed significantly higher rates of overall survival (HR 0.43, 95%CI 0.35-0.53). In addition, triple therapy was associated with significantly longer median progression-free survival (15.9 vs. 8.0 mo, p <0.001). These results were confirmed in matched subsets of patients from each group. However, subgroup analysis confirmed the results only for patients with HCC in intermediate or advanced stages, not in an early stage. Those who received triple conversion therapy had a significantly higher rate of hepatectomy after conversion therapy (36.4 vs. 23.5%, p <0.001). Among those who underwent hepatectomy after conversion therapy, triple therapy was associated with a significantly higher rate of complete tumor response (32.1 vs. 11.1%, p <0.001). However, it was also associated with a significantly higher frequency of serious adverse events (35.6 vs. 27.0%, p =0.009).

CONCLUSIONS

Combining TACE with immune checkpoint and tyrosine kinase inhibitors was associated with significantly better survival and conversion efficacy than TACE alone among patients with intermediate or advanced unresectable HCC.

Transarterial chemoembolization combined with lenvatinib and sintilimab vs lenvatinib alone in intermediate-advanced hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the most common form of liver cancer that has limited treatment options and a poor prognosis. Transarterial chemoembolization (TACE) is the first-line treatment for intermediate-stage HCC but can induce tumour hypoxia, thereby promoting angiogenesis. Recent studies suggested that combining TACE with anti-angiogenic therapies and immunotherapy might improve efficacy. Lenvatinib, a tyrosine kinase inhibitor, has demonstrated superior outcomes compared to sorafenib, while immune checkpoint inhibitors such as sintilimab show potential when combined with TACE. However, the efficacy and safety of TACE combined with lenvatinib and sintilimab (TACE + SL) compared to TACE with lenvatinib alone (TACE + L) in patients with intermediate-advanced HCC has not yet been investigated.

AIM

To evaluate the efficacy and safety of TACE + SL therapy in comparison to TACE + L therapy in patients with intermediate-advanced HCC.

METHODS

A retrospective analysis was performed on patients with intermediate-advanced HCC who received TACE plus lenvatinib with or without sintilimab between September 2019 and September 2022. Baseline characteristics were compared, and propensity score matching was applied. Overall survival (OS), progression-free survival (PFS), and objective response rate (ORR) were evaluated between the two groups, and adverse events were analyzed.

RESULTS

The study included 57 patients, with 30 in the TACE + SL group and 27 in the TACE + L group. The TACE + SL group demonstrated significantly improved median PFS and OS compared to the TACE + L group (PFS: 14.1 months vs 9.6 months, P = 0.016; OS: 22.4 months vs 14.1 months, P = 0.039), along with a higher ORR (70.0% vs 55.6%). After propensity score matching, 30 patients were included, with the TACE + SL group again showing longer median PFS and a trend toward improved OS (PFS: 14.6 months vs 9.2 months, P = 0.012; OS: 23.9 months vs 16.3 months, P = 0.063), and a higher ORR (73.3% vs 53.3%). No severe adverse events were reported.

CONCLUSION

TACE + SL demonstrated superior outcomes in terms of OS and PFS, compared to TACE + L. These findings suggest that the addition of sintilimab might enhance the therapeutic response in patients with intermediate-advanced HCC.

Prognostic impact of primary versus secondary resistance to sorafenib in patients with HCC

Background

Sorafenib is a first-line treatment option for patients with hepatocellular carcinoma (HCC). However, the impact of sorafenib resistance type on patient survival prediction and choice of second-line treatment regimen is unknown.

Objectives

This study aims to explore the factors predicting resistance in patients with HCC receiving sorafenib, the impact of resistance on survival, and the optimal second-line treatment regimen.

Design

This was a retrospective cohort study.

Methods

We recruited all patients with advanced HCC who received first-line sorafenib from January 2019 to January 2023 in two medical centers in China. They were divided into primary and secondary resistance groups according to tumor progression within 3 months. Resistance was the primary outcome of this study. The secondary outcomes were progression-free survival (PFS) and overall survival (OS).

Results

A total of 424 patients met the inclusion criteria, including 165 patients (38.9%) in the primary group and 259 patients (61.1%) in the secondary group. The independent risk factors for primary resistance were alpha-fetoprotein (AFP) > 400 ng/mL and alanine aminotransferase (ALT) > 40 U/L. Patients in the primary group had significantly shorter median OS than those in the secondary group (9.0 months vs 23.0 months, p < 0.001). Compared with tyrosine kinase inhibitor (TKI) monotherapy, the use of TKI plus PD-1 inhibitor combination therapy as second-line treatment conferred a longer median PFS (6.0 vs 10.0 months, p < 0.001) and OS (13.0 vs 22.0 months, p < 0.001).

Conclusion

Sorafenib has a high incidence of primary resistance and short survival in patients who develop primary resistance. AFP and ALT are influential factors in primary resistance, and it is valuable to use these two metrics to guide the use of sorafenib. As second-line therapy, a TKI plus PD-1 inhibitor regimen should be preferentially recommended.

Resistance mechanisms to immune checkpoint inhibitors: updated insights

The last decade has witnessed unprecedented succusses with the use of immune checkpoint inhibitors in treating cancer. Nevertheless, the proportion of patients who respond favorably to the treatment remained rather modest, partially due to treatment resistance. This has fueled a wave of research into potential mechanisms of resistance to immune checkpoint inhibitors which can be classified into primary resistance or acquired resistance after an initial response. In the current review, we summarize what is known so far about the mechanisms of resistance in terms of being tumor-intrinsic or tumor-extrinsic taking into account the multimodal crosstalk between the tumor, immune system compartment and other host-related factors.

Chinese expert consensus on sequential surgery following conversion therapy based on combination of immune checkpoint inhibitors and antiangiogenic targeted drugs for advanced hepatocellular carcinoma (2024 edition)

Up to half of hepatocellular carcinoma (HCC) cases are diagnosed at an advanced stage, for which effective treatment options are lacking, resulting in a poor prognosis. Over the past few years, the combination of immune checkpoint inhibitors and anti-angiogenic targeted therapy has proven highly efficacious in treating advanced HCC, significantly extending patients' survival and providing a potential for sequential curative surgery. After sequential curative hepatectomy or liver transplantation following conversion therapy, patients can receive long-term survival benefits. In order to improve the long-term survival rate of the overall population with liver cancer and achieve the goal of a 15% increase in the overall 5-year survival rate outlined in the Healthy China 2030 blueprint, the Professional Committee for Prevention and Control of Hepatobiliary and Pancreatic Diseases of Chinese Preventive Medicine Association, Chinese Society of Liver Cancer, and the Liver Study Group of Surgery Committee of Beijing Medical Association organized in-depth discussions among relevant domestic experts in the field. These discussions focused on the latest progress since the release of the Chinese expert consensus on conversion therapy of immune checkpoint inhibitors combined antiangiogenic targeted drugs for advanced hepatocellular carcinoma (2021 Edition) and resulted in a new consensus on the modifications and supplements to related key points. This consensus aims to further guide clinical practice, standardize medical care, and promote the development of the discipline.

Advances in systemic therapy leading to conversion surgery for advanced hepatocellular carcinoma

Recently, a systemic therapy for advanced hepatocellular carcinoma (HCC) has been developed. The regimen for unresectable HCC varies and includes single or multi-tyrosine kinase inhibitors, monoclonal antibodies, immune checkpoint inhibitors, or their combinations. Treatment with these agents begins with sorafenib as the first-line drug for unresectable HCC. Subsequently, several systemic therapies, including lenvatinib, ramucirumab, cabozantinib, and regorafenib have been investigated and established. With advances in systemic therapy for unresectable HCC, the prognosis of patients with unresectable HCC has improved significantly than previously. Conversion surgery, consisting of systemic therapy and surgery, showed the possibility of improving the prognosis than systemic therapy alone. Although a combination of atezolizumab and bevacizumab is mostly used for initially unresectable HCC to conduct conversion surgery because of the high response rate and fewer adverse events compared to others, many trials are being conducted to assess their efficacy for initially unresectable HCC. However, the appropriate timing of surgery and interval between systemic therapy and surgery remain controversial. To address these issues, a multidisciplinary team can play a vital role in determining the strategies for treating unresectable HCC. This review describes previous and current trends in the treatment of HCC, with a particular focus on conversion surgery for initially unresectable HCC.

Hepatic arterial infusion chemotherapy combined with immune checkpoint inhibitors and molecular targeted therapies for advanced infiltrative hepatocellular carcinoma: a single-center experience

Background

Infiltrative hepatocellular carcinoma (HCC) remains a therapeutic challenge due to its aggressive course and poor prognosis. Hepatic arterial infusion chemotherapy (HAIC) plus immune checkpoint inhibitors (ICIs) and molecular targeted therapies (MTTs) has shown early promise for advanced HCC, but its role in advanced infiltrative HCC is unclear. This study aims to investigate the efficacy and safety of HAIC combined with ICIs and MTTs in the treatment of advanced infiltrative HCC.

Methods

Patients with infiltrative HCC initially treated with HAIC plus ICIs and MTTs were consecutively included at our institution from November 2021 to June 2023. The efficacy evaluation included tumor response, time to response (TTR), duration of response (DOR), progression-free survival (PFS) per RECIST 1.1, and patient survival. Adverse events (AEs) were recorded for safety evaluation.

Results

A total of 27 patients were included and the median follow-up was 15.8 months (range, 4.3-25.9). The best objective response rate (ORR) and disease control rate (DCR) were 70.4% and 88.9%, respectively. The median TTR was 2.8 months (95% confidence interval [CI], 2.6-3.0) and the median DOR was 7.9 months (95% CI, 3.2-12.5). The median PFS was 7.5 months (95% CI, 4.2-10.7), and the median overall survival (OS) was 16.8 months (95% CI, 14.0-19.6), with a 1-year OS rate of 74.1%. No cases of grade 4 or 5 treatment-related adverse events (TRAEs) were observed in this study. Grade 3 TRAEs occurred in 17/27 (63.0%) patients, and the predominant grade 3 treatment-related adverse events were lymphocyte count decreased (18.5%) and neutrophil count decreased (14.8%).

Conclusions

The combination of HAIC plus ICIs and MTTs demonstrated encouraging outcomes and manageable safety concerns for infiltrative HCC.

Cost-effectiveness of the addition of sintilimab as a first-line therapy for locally advanced or metastatic oesophageal squamous cell carcinoma: a Chinese healthcare system perspective

BACKGROUND

The ORIENT-15 double-blind randomized controlled trial demonstrated that the addition of sintilimab to chemotherapy for locally advanced or metastatic oesophageal squamous cell carcinoma (OSCC) resulted in better clinical outcomes. In this analysis, we sought to evaluate the cost-effectiveness of sintilimab as a first-line treatment for locally advanced or metastatic OSCC from a healthcare system perspective in China.

METHODS

A partitioned survival model was constructed to perform a cost-effectiveness analysis comparing chemotherapy alone with sintilimab for locally advanced or metastatic OSCC patients. Clinical data were obtained from the ORIENT-15 trial and extrapolated to 10 years. Health state utilities and costs were sourced from the literature and from public healthcare institutions. The primary outcomes included the incremental cost-effectiveness ratio (ICER) and quality-adjusted life-years (QALYs). Two different sensitivity analyses, one-way and probabilistic, were performed to assess model uncertainty.

RESULTS

Sintilimab-based chemotherapy was more costly ($31699.21 vs. $20687.42) and more effective (0.74 vs. 0.53) than placebo-based chemotherapy, resulting in an ICER of $51908.19 /QALY, which is greater than the willingness-to-pay (WTP) threshold of China ($38223/QALY). Sensitivity analysis demonstrated that the PFS and cost of sintilimab were the major influencing factors affecting the results.

CONCLUSIONS

In patients with locally advanced or metastatic OSCC, sintilimab chemotherapy could improve survival time and health benefits compared with traditional chemotherapy, but the present analysis suggests that sintilimab is not a cost-effective treatment option in China.

Neoadjuvant therapy with triple therapy for centrally located hepatocellular carcinoma

BACKGROUND

Centrally located hepatocellular carcinoma (HCC) is a subtype HCC with special location adjoined hepatic portals. It is difficult to be radically resected with sufficient surgical margin. We discussed whether neoadjuvant therapy could increase surgical margin and reduce recurrence.

METHODS

From January 2018 to September 2023, 106 centrally located HCC patients who underwent radical liver resection were retrospectively included. Neoadjuvant therapy included transarterial chemoembolization (TACE) with programmed death 1 (PD-1) inhibitors plus tyrosine kinase inhibitor (TKI). Surgical margin and long-term outcomes were compared between patients with and without neoadjuvant therapy.

RESULTS

40 patients underwent neoadjuvant therapy and 66 patients underwent surgery alone. In neoadjuvant therapy group, 3 (7.5 %) patients achieved progression disease, 9 (22.5 %) patients achieved stable disease, 13 (32.5 %) achieved partial response and 15 (37.5 %) achieved complete response based on the mRECIST criterion. Ultimately, 36 patients (90 %) underwent subsequent surgical resection in the neoadjuvant therapy group. The neoadjuvant therapy had the advantages of declining alpha fetoprotein level (5.9 ng/mL vs 50.1 ng/mL, P = 0.001), microvascular invasion rate (MVI) (12.5 % vs 30.3 %, P = 0.036), reducing tumor size to 5.1 ± 2.1 cm from 6.2 ± 2.2 cm (P = 0.021), and increasing more patients with surgical margin>1 cm (30.0 % vs 7.6 %, P = 0.002). The neoadjuvant therapy group reduced tumor recurrence and prolonged overall survival. Multivariate analysis found that neoadjuvant therapy was an independent protective factor for overall survival and recurrence free survival.

CONCLUSIONS

Neoadjuvant therapy showed advantage of reducing tumor burden and increasing surgical margin for centrally located HCC, resulting in longer overall survival and recurrence free survival.

CD96: immunoregulation and its role and prospect in immunotherapy of primary hepatocellular carcinoma

Recently, immune checkpoint inhibitors have been widely used in the treatment of advanced liver cancer. Immune checkpoints are a type of molecules that play an important role in the self-regulation of the immune system. In tumor immunity, their activation by immune checkpoints leads to the inhibition of effector lymphocyte activation or the mediation of cytotoxic T cell dysfunction, resulting in immune escape. These immune checkpoints include programmed death receptor 1 (PD-1) and its ligand PD-L1, as well as cytotoxic T lymphocyte-associated protein 4 (CTLA-4) and others. Immune checkpoint inhibitors block the interaction between immune checkpoint receptors and ligands, thereby relieving the immune suppression caused by immune checkpoints, and reactivating immune cells to exert antitumor effects. With the continuous progress of immunotherapy research, drugs targeting PDL-1, PD-1, and CTLA-4 have played an important role in clinical treatment. However, some patients still cannot benefit from immunotherapy; therefore, multitarget immunotherapy is an important way to improve the response rate of immunotherapy. CD96 is one of the members of the immunoglobulin superfamily receptors, which mainly functions by regulating natural killer cells and CD8+ T cells, and is expected to become a new generation of immune checkpoints. This article reviews the molecular structure of CD96, its role in tumor immunity, and its application in hepatocellular carcinoma, hoping to provide reference for related research.

Phase 2 study of serplulimab with the bevacizumab biosimilar HLX04 in the first-line treatment of advanced hepatocellular carcinoma

INTRODUCTION

This study aimed to evaluate the safety and preliminary efficacy of serplulimab, a novel programmed death-1 inhibitor, with or without bevacizumab biosimilar HLX04 as first-line treatment in patients with advanced hepatocellular carcinoma.

METHODS

This open-label, multicenter phase 2 study (clinicaltrials.gov identifier NCT03973112) was conducted in China and consisted of four treatment groups: group A (serplulimab 3 mg/kg plus HLX04 5 mg/kg, subsequent-line), group B (serplulimab 3 mg/kg plus HLX04 10 mg/kg, subsequent-line), group C (serplulimab 3 mg/kg, subsequent-line) and group D (serplulimab 3 mg/kg plus HLX04 10 mg/kg, first-line). Group D was the only group in which participants received the study treatment in the first-line setting. The primary endpoint was safety.

RESULTS

Following previous report on groups A and B, results of group D are herein presented. As of February 7, 2023, 61 patients were enrolled and were followed up for a median of 25.5 months. Grade ≥ 3 treatment-emergent adverse events were reported by 29 (47.5%) patients. One patient died from adverse events that were considered related to study treatment. Among the patients with at least one post-baseline tumor assessment (n = 58), the objective response rate was 29.3% (95% CI: 18.1-42.7) as assessed by an independent radiological review committee (IRRC) per RECIST v1.1. IRRC-assessed median progression-free survival was 7.3 months (95% CI: 2.8-11.0), and median overall survival was 20.4 months (95% CI: 15.0-NE), respectively.

CONCLUSION

Serplulimab combination therapy with HLX04 showed a manageable safety profile as well as preliminary efficacy in patients with advanced HCC in the first-line setting.

Metastasis-directed ablation of hepatocellular carcinoma with pulmonary oligometastases: a long-term multicenter study

PURPOSE

Ablation is a promising approach for eliminating intrathoracic metastases. We compared the effectiveness of a combination of metastasis-directed ablation and systemic therapy with that of systemic therapy alone for patients with hepatocellular carcinoma (HCC) having pulmonary oligometastases.

MATERIALS AND METHODS

We analyzed 679 patients with HCC and pulmonary oligometastases from seven tertiary hospitals. A total of 372 patients received systemic therapy (System group), whereas 307 patients received the combination therapy of pulmonary oligometastases ablation and systemic therapy (Ablation + System group).

RESULTS

The median progression-free survival (PFS) was 9.7 ± 0.6 and 11.5 ± 0.6 months in the System and Ablation + System groups, respectively. The Ablation + System group exhibited significantly better PFS (hazard ratio [HR], 0.71; 95% confidence interval [CI] 0.60-0.85; P < 0.001) and overall survival (OS) (HR, 0.65; 95% CI 0.52-0.81; P < 0.001) than the System group. The subgroup analysis revealed that OS (HR, 0.91; 95% CI 0.65-1.28; P = 0.590) and PFS (HR, 0.81; 95% CI 0.62-1.05; P = 0.100) did not differ between tyrosine kinase inhibitor (TKI) and TKI plus programmed cell death protein-1 (PD-1) inhibitor therapies in the Ablation + system group. In addition, PFS (HR, 0.53; 95% CI 0.38-0.74; P < 0.001) and OS (HR, 0.66; 95% CI 52-0.84; P < 0.001) showed obviously different for intrahepatic tumors with partial response (PR) status.

CONCLUSION

The application of a combination of ablation of pulmonary oligometastases and systemic therapy resulted in longer PFS and OS than systemic therapy alone.

Serum Alpha-fetoprotein Associated with Treatment Efficacy of Immune Checkpoint Inhibitors in Patients with Hepatocellular Carcinoma: A Meta-Analysis and a Retrospective Cohort Study

Context: Serum alpha-fetoprotein (AFP) has been shown to be valuable in tumor staging and predicting survival outcomes. In this investigation, we conducted a retrospective cohort analysis and a meta-analysis to assess the predictive significance of initial AFP levels in patients with hepatocellular carcinoma (HCC) who underwent treatment with immune checkpoint inhibitors (ICIs). Methods: We searched databases from inception until 14 July 2024 to identify cohort studies involving ICI treatments in HCC patients with baseline AFP data. We also retrospectively analyzed patients with HCC treated with ICIs to assess the therapeutic effect in the high AFP (AFP ≥ 400 ng/mL) group and the low AFP (AFP < 400 ng/mL) group in terms of overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and disease control rate (DCR). Results: In the meta-analysis, a total of 34 studies, comprising 8,799 patients, were included, while the retrospective cohort study encompassed 55 patients. In the meta-analysis, the summarized hazard ratios (HRs) of AFP ≥ 400 ng/mL versus AFP < 400 ng/mL for ICI therapy indicated that the high AFP group had a poorer outcome compared to the low AFP group, with a pooled HR for OS of 1.69 (95% CI: 1.57 - 1.82, P < 0.001) and a pooled HR for PFS of 1.47 (95% CI: 1.33 - 1.63, P < 0.001). In the retrospective cohort study, higher AFP levels were associated with a lower DCR for ICIs, with a DCR of 42.9% in the high AFP group and 77.8% in the low AFP group (P = 0.008). Cox model analysis showed that higher serum AFP was an independent predictor for shorter OS (HR 3.584, 95% CI: 1.466 - 8.762, P = 0.005). The toxicity analysis also displayed a strong association between high AFP and the occurrence of immune-related adverse events (irAEs) (P = 0.008). Conclusions: Higher serum AFP is associated with poorer efficacy of ICI treatment in HCC patients.

Hepatic arterial chemotherapy infusion combined with tyrosine kinase inhibitors and PD-1 inhibitors for advanced hepatocellular carcinoma with high risk: a propensity score matching study

OBJECTIVE

To ascertain the therapeutic efficacy and safety of FOLFOX (oxaliplatin, fluorouracil, and leucovorin)-based hepatic arterial infusion chemotherapy combined with tyrosine kinase inhibitors (TKI) and programmed cell death protein-1 inhibitors (PD-1 inhibitors) (triple therapy), as a first-line treatment in high-risk advanced hepatocellular carcinoma (aHCC with Vp4 portal vein invasion or/and tumor diameter ≥10 cm).

METHODS

This retrospective multicenter study included 466 high-risk aHCC patients treated with either triple therapy ( n =245) or dual therapy (TKI and PD-1 inhibitors, n =221). The overall survival, progression-free survival, objective response rate, and safety were compared between the two groups. Propensity score matching was performed to reduce bias between the two groups.

RESULTS

After propensity score matching (1:1), 194 patients in each group were analyzed. The triple-therapy group showed a longer median overall survival (24.6 vs. 11.9 months; HR=0.43, P <0.001) and a longer median progression-free survival (10.0 vs. 7.7 months; HR=0.68, P =0.002) than the dual-therapy group. The survival rates at 6, 12, and 24 months were 94.2, 71.0, and 50.8% for triple therapy and 75.9, 49.9, and 26.8% for dual therapy. The objective response rate in the triple-therapy group was significantly higher (57.7 vs. 28.9%, P <0.001). In the triple-therapy group, more patients converted to non-high-risk (68.0 vs. 36.6%, P <0.001) and received salvage liver resection or ablation after downstaging conversion (16.5% vs. 9.2%, P =0.033). The grade 3/4 adverse events were 59.2 and 47.4% in the triple-therapy group and dual-therapy group, respectively ( P =0.022).

CONCLUSION

FOLFOX-based hepatic arterial infusion chemotherapy plus TKI and PD-1 inhibitors significantly improve survival prognosis compared with TKI plus PD-1 inhibitors. This is a potential first-line treatment for high-risk aHCC, with a relatively controlled safety profile.

Dynamic changes of serum α-fetoprotein predict the prognosis of bevacizumab plus immunotherapy in hepatocellular carcinoma

BACKGROUND

Alpha-fetoprotein (AFP) has been established as a biomarker for hepatocellular carcinoma (HCC); however, whether its dynamic changes could predict the response to systemic therapy remains elusive. This study explored the AFP trajectory and the association with survival in patients who received bevacizumab plus immunotherapy.

MATERIALS AND METHODS

We retrospectively enrolled 536 HCC patients who received bevacizumab plus immunotherapy between February 2021 and February 2023. Patients were divided into two groups according to AFP values before treatment (400 ng/ml). Dynamic changes of AFP were fitted using a latent class model to generate the AFP trajectories. Multivariable Cox models were utilized to compute hazard ratios (HRs) for survival. Inverse-probability-of-treatment weighted analyses were conducted to mitigate the influence of unmeasured confounding variables. The primary endpoint is progression-free survival (PFS). The second endpoint is overall survival (OS).

RESULTS

Three distinct trajectories were identified for AFP-low and AFP-high patients, respectively. In the AFP-low group, compared with the high-rising class (25%; n =69), HRs of PFS were 0.39 and 0.2 for the low-stable class (59.1%; n =163) and sharp-falling class (15.9%; n =44), after adjusting by tumor diameter, tumor number, and extra-hepatic metastasis. In the AFP-high group, compared with the high-stable class (18.5%; n =48), HRs of PFS were 0.3 and 0.04 for the middle-stable class (56.5%; n =147) and sharp-falling class (25%; n =65), after adjusting by tumor diameter, tumor number, and extra-hepatic metastasis. Furthermore, the AFP trajectories exhibited the utmost relative importance among all covariates regarding PFS and OS in the multivariable regression models.

CONCLUSION

The AFP trajectories in HCC patients receiving bevacizumab and immunotherapy constituted an independent biomarker indicative of clinical outcomes. Findings from this study hold potential clinical utility in dynamically forecasting the prognosis of systemic therapy in HCC patients and facilitating clinical decision-making. Rapid reduction of AFP post-treatment can lead to favorable patient prognoses.

Hepatic arterial infusion chemotherapy combined with lenvatinib and PD-1 inhibitors versus lenvatinib and PD-1 inhibitors for unresectable HCC: a meta-analysis

Objectives

This study aimed to evaluate the effectiveness of combining hepatic arterial infusion chemotherapy (HAIC) with lenvatinib and programmed cell death protein 1 (PD-1) inhibitors in the treatment of advanced, unresectable hepatocellular carcinoma (HCC).

Methods

A comprehensive search across multiple databases was conducted to identify relevant studies published up to May 2024. This search focused on clinical trials investigating the combination of HAIC with lenvatinib and PD-1 inhibitors for the treatment of advanced HCC. Data from these trials were analyzed using either fixed-effects or random-effects models, with results reported as hazard ratios (HRs) or risk ratios (RRs) with 95% confidence intervals (CIs). To evaluate the robustness of the findings, trial sequential analysis was employed.

Results

A total of 8 cohort studies encompassing 1073 patients with unresectable HCC were included. Compared with other treatment regimens, the combined use of HAIC, lenvatinib, and PD-1 inhibitors significantly improved overall survival (OS) (HR=0.53 [95% CI 0.45, 0.63], P<0.00001), progression-free survival (PFS) (HR 0.56 [95% CI 0.46, 0.61], P<0.0001), the objective response rate (ORR) (RR=1.82 [95% CI 1.52, 2.18], P<0.00001), and the disease control rate (DCR) (RR=1.24 [95% CI 1.16, 1.33], P<0.00001). Trial sequential analysis (TSA) results indicated that the existing data were sufficient for making quantitative conclusions about the ORR and DCR.

Conclusion

Combining HAIC with lenvatinib and PD-1 inhibitors enhances the effectiveness of treatment for unresectable HCC. This approach is particularly beneficial for patients who have a high tumor burden or those who are refractory to transarterial chemoembolization (TACE), providing a more effective solution for these challenging cases.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024575853, identifier CRD42024575853.

Bibliometric study on the utilization of sorafenib in hepatocellular carcinoma

Background

Although the number of studies on sorafenib for hepatocellular carcinoma (HCC) is increasing during the past two decades, no detailed scientometric examination of its knowledge framework has been undertaken. Therefore, we performed a bibliometric analysis on this topic.

Methods

VOSviewer and CiteSpace were utilized to analyze the articles regarding sorafenib for HCC from 2005 to 2024, which were retrieved from the Web of Science Core Collection (WoSCC) database.

Results

There were 7,667 articles related to sorafenib in HCC were retrieved from the WoSCC database, and they covered 99 countries/regions, 5,640 institutions, and 30,450 authors. The most published literature of countries and institutions were China and Sun Yat-sen University, respectively. Cancers is the journal with the most papers published in this field, and the journal with the most co-citations is N Engl J Med. Among authors, Masatoshi Kudo has published the most research papers, and the most co-citations go to JM Llovet. The keywords "survival", "apoptosis", "efficacy", "transarterial chemoembolization", "lenvatinib", etc. represent the current hotspots in this field.

Conclusions

We identified current hotspots and trends by bibliometric analysis in sorafenib-HCC field, which might provide valuable guidance for future researches. Further explorations are supposed to conduct the continued study of HCC apoptosis, large-scaled clinical trials with international cooperations, and comprehensive treatments including multiple systemic or locoregional approaches in patients with HCC.

Current efficacy of hepatic arterial infusion chemotherapy in hepatocellular carcinoma

Newer systemic therapies for hepatocellular carcinoma (HCC) have led to growing interest in combining hepatic arterial infusion chemotherapy (HAIC) with systemic treatments. To evaluate the effectiveness and safety of HAIC and combination therapies in treating advanced HCC, a network meta-analysis was conducted by Zhou et al. The study included data from 44 articles. HAIC was superior in overall survival (OS), progression-free survival (PFS), and response rates compared to transarterial chemoembolization and sorafenib. Moreover, combinations of HAIC with other treatments and single agents (e.g., lenvatinib, ablation, anti-programmed cell death 1 therapy, radiotherapy) provided better OS and PFS outcomes than HAIC alone. In this editorial, we will discuss the study findings, the strengths and weaknesses of the metanalysis, and future advances in the field of HAIC for advanced HCC.

Prognostic significance of early alpha fetoprotein and des-gamma carboxy prothrombin responses in unresectable hepatocellular carcinoma patients undergoing triple combination therapy

Background

Recent advancements in combination therapy for unresectable hepatocellular carcinoma (uHCC) have shown promise, but reliable serological prognostic indicators are currently lacking for patients undergoing triple combination therapy of stereotactic body radiation therapy (SBRT), immunotherapy, and targeted therapy. We aimed to investigate the prognostic significance of early alpha fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) responses in these patients.

Methods

This retrospective research included 115 uHCC patients treated with SBRT in combination with immunotherapy and targeted therapy (triple therapy) at our institution from April 2021 to December 2022. Participants were categorized into high AFP and high DCP cohorts based on baseline levels. AFP and DCP responses were defined as decreases from baseline of over 50% and 70%, respectively, according to ROC curve analysis. Differences in overall survival (OS), progression-free survival (PFS), and objective response rate (ORR) were assessed between the tumor biomarker response and non-response groups.

Results

Multivariate analysis indicated that AFP or DCP response at 6-8 weeks post-therapy significantly influenced ORR (high AFP cohort: odds ratio [OR] 5.50, 95% CI 2.04-14.83, p=0.001; high DCP cohort: OR 7.99, 95%CI 2.82-22.60, p<0.001). The median PFS was notably longer in tumor biomarker response groups (high AFP cohort: 13.7 vs 6.2 months, hazard ratio [HR] 0.36, 95% CI 0.20-0.62, p<0.001; high DCP cohort: 15.6 vs 9.3 months, HR 0.44, 95% CI 0.26-0.74, p=0.002). AFP or DCP response was associated with prolonged OS (high AFP cohort: not reached vs. 21.9 months, HR 0.47, 95% CI 0.22-0.99, p=0.047; high DCP cohort: not reached vs. 20.6 months, HR 0.35, 95% CI 0.14-0.86, p=0.022).

Conclusion

AFP or DCP response at 6-8 weeks post-therapy predicts better oncological outcomes in patients with uHCC treated with triple therapy.

Case report: Combination therapy for hepatocellular carcinoma with inferior vena cava or right atrial tumor thrombus in the era of combined targeted and immunotherapeutic agents

Primary liver cancer, predominantly hepatocellular carcinoma (HCC), is a leading cause of cancer-related mortality. Tumor thrombus (TT) in the inferior vena cava (IVC) or right atrium (RA) significantly worsens prognosis. We present four cases of male patients (average age 57) with HCC and TT extending into the IVC/RA, treated at our center. All underwent hepatectomy and TT resection, with targeted therapy (lenvatinib) and immunotherapy (sintilimab) administered post-operatively. Case 1 involved a 59-year-old male who had a right hepatectomy and TT resection in the IVC, followed by targeted therapy and immunotherapy, and is currently alive 74 months post-treatment. Case 2, a 48-year-old male, had a right hepatic lobectomy and TT resection in the IVC/RA, followed by liver transplantation 54 months postoperatively, with no recurrence. Case 3, a 66-year-old male, underwent a left hepatectomy and TT resection in the IVC, remaining disease-free 27 months postoperatively. Case 4, a 55-year-old male, received 15 cycles of combined targeted and immune therapy, followed by left hepatectomy and TT resection in the IVC/RA, with no recurrence 22 months postoperatively. Surgical resection combined with targeted and immunotherapy may enhance survival in advanced HCC patients with TT in the IVC/RA. Further studies are required to corroborate these findings.

Immune checkpoint inhibitors and the liver: balancing therapeutic benefit and adverse events

Immune checkpoint inhibitors (ICI) have led to breakthrough improvements in the management of malignancy including hepatocellular (HCC) and biliary tract cancer, improving decades-old standards of care and increasing patient survival. In both liver tumour types, which commonly arise in the context of liver inflammation and underlying functional impairment, the lack of validated predictors of response underscores the need to balance predicted gains in survival with risk of treatment-related hepatoxicity and decompensation of underlying chronic liver disease.In addition, the liver is implicated in the toxicity associated with ICI therapy for non-liver cancers, which exhibits a high degree of variability in presentation and severity. An accurate assessment is mandatory for the diagnosis and management of ICI-induced liver injury.In this Recent Advances article, we provide an overview of the mechanisms of efficacy and toxicity of anticancer immunotherapy in liver tumours and liver toxicity in extrahepatic malignancies.We compare and contrast characteristics, management strategies and outcomes from immune-related liver injury in patients with chronic hepatitis/cirrhosis or with an underlying healthy liver and discuss the latest findings on how toxicity and decompensation may impact the outlook of patients with liver tumours and extrahepatic malignancies offering insights into the future directions of clinical research and practice in the field.