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Díaz-González Á, Sapena V, Boix L, Torres F, Sanduzzi-Zamparelli M, Da Fonseca LG, LLarch N, Iserte G, Guedes C, Muñoz-Martínez S, Darnell A, Belmonte E, Rimola J, Forner A, Ayuso C, Bruix J, Reig M. Early diarrhoea under sorafenib as a marker to consider the early migration to second-line drugs. United European Gastroenterol J 2021; 9:655-661. [PMID: 34228394 PMCID: PMC8280813 DOI: 10.1002/ueg2.12111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/14/2021] [Accepted: 03/31/2021] [Indexed: 12/24/2022] Open
Abstract
Background Despite atezolizumab and bevacizumab (A + B) is currently the first‐line treatment for hepatocellular carcinoma (HCC) patients, some patients will not be adequate for this combination. In the setting of sorafenib some adverse events have been proposed as prognostic factors. Objective To characterize the early diarrhoea development as prognostic factor in 344 HCC patients. Methods The development of early diarrhoea in sorafenib treatment defined as patients who developed diarrhoea and needed dose modification within the first 60 days of treatment (e‐diarrhoea) and 3‐grouping variables were analysed: Patients with e‐diarrhoea, patients who developed diarrhoea after the first 60 days of treatment (L‐diarrhoea) and patients that never developed diarrhoea (never diarrhoea). Results The median overall survival in sorafenib treated patients was significantly different across groups (6.8 months for e‐diarrhoea, 26.7 months for L‐diarrhoea and 13.3 months for never‐diarrhoea). The emergence of e‐diarrhoea was associated with poor outcomes (hazard ratio [HR] 1.84 [95%CI 1.15–2.95]), while there was no increased/decreased risk of dismal evolution in patients with L‐diarrhoea (HR 0.66 [95%CI 0.42–1.03]). Conclusion The emergence of e‐diarrhoea in HCC patients treated with sorafenib is an early predictor of dismal evolution under this therapy. Thus, prompt identification of these non‐responders may be useful for an early switch to second‐line therapies. Established knowledge on this subjectDiarrhoea is a frequent adverse event of sorafenib and its emergence has been associated to better outcomes.
What are the significant and/or new findings of this study?Early diarrhoea (e‐diarrhoea) in hepatocellular carcinoma patients treated with sorafenib is an early predictor of dismal evolution. Diarrhoea under sorafenib should not be taken as a predictive parameter of lack of benefit. E‐diarrhoea could be used as clinical biomarker for switching to second‐line therapies.
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Affiliation(s)
- Álvaro Díaz-González
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Víctor Sapena
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Loreto Boix
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Ferrán Torres
- Medical Statistics Core Facility, IDIBAPS. Hospital Clínic de Barcelona. Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marco Sanduzzi-Zamparelli
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Leonardo G Da Fonseca
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Neus LLarch
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Gemma Iserte
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Cassia Guedes
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Sergio Muñoz-Martínez
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Anna Darnell
- Barcelona Clinic Liver Cancer (BCLC) Group. Radiology Department, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Ernest Belmonte
- Barcelona Clinic Liver Cancer (BCLC) Group. Radiology Department, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Jordi Rimola
- Barcelona Clinic Liver Cancer (BCLC) Group. Radiology Department, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Alejandro Forner
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Carmen Ayuso
- Barcelona Clinic Liver Cancer (BCLC) Group. Radiology Department, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - Jordi Bruix
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
| | - María Reig
- Barcelona Clinic Liver Cancer (BCLC) Group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd. University of Barcelona, Barcelona, Spain
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Díaz-González Á, Sapena V, Boix L, Brunet M, Torres F, LLarch N, Samper E, Millán O, Corominas J, Iserte G, Sanduzzi-Zamparelli M, da Fonseca LG, Darnell A, Belmonte E, Forner A, Ayuso C, Bruix J, Reig M. Pharmacokinetics and pharmacogenetics of sorafenib in patients with hepatocellular carcinoma: Implications for combination trials. Liver Int 2020; 40:2476-2488. [PMID: 33021346 DOI: 10.1111/liv.14587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Sorafenib and lenvatinib are the first-line treatments approved in hepatocellular carcinoma (HCC), but information is lacking about the relationships between their pharmacokinetics, patients pharmacogenetic profiles, adverse events (AE) and overall survival. We aimed to elucidate these relationships of tyrosine Kinase Inhibitors, such as sorafenib, in order to improve the design of trials testing it in combination with checkpoint inhibitors. METHODS We assessed the pharmacokinetics of sorafenib and its N-oxide metabolite at day-0, day-7, day-30, day-60, day-90, day-120, day-150 and day-180 and nine single-nucleotide polymorphisms (SNP) in five genes related to sorafenib metabolism/transport to identify the best point for starting the combination between tyrosine kinases and checkpoint inhibitors. RESULTS We prospectively included 49 patients (96% cirrhotic, 37% hepatitis-C, 82% Child-Pugh-A and 59% BCLC-C). Pharmacokinetic values peaked at day-7 and progressively declined until day-60. In the 16 patients without further dose modifications after day-60, pharmacokinetic values remained stable through day-180 (sorafenib P = .90; N-oxide P = .93). Pharmacokinetic values were higher in patients with early dermatological adverse events and lower in patients with early diarrhoea. Sorafenib and N-oxide pharmacokinetic values varied linearly with different alleles of MRP2*3972. CONCLUSIONS Sorafenib's pharmacokinetics is heterogeneous across HCC patients. This heterogeneity affects adverse events development and must be taken into account in setting the dose and timing of its combination with checkpoint inhibitors.
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Affiliation(s)
- Álvaro Díaz-González
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Víctor Sapena
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Loreto Boix
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Mercè Brunet
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Ferrán Torres
- Medical Statistics Core Facility, IDIBAPS. Hospital Clínic de Barcelona. Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Neus LLarch
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Esther Samper
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Olga Millán
- Pharmacology and Toxicology Laboratory, Biochemistry and Molecular Genetics Department, Biomedical Diagnostic Center, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Josep Corominas
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Gemma Iserte
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Marco Sanduzzi-Zamparelli
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Leonardo G da Fonseca
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Anna Darnell
- BCLC group. Radiology department, Hospital Clínic de Barcelona. IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Ernest Belmonte
- BCLC group. Radiology department, Hospital Clínic de Barcelona. IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Alejandro Forner
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - Carmen Ayuso
- BCLC group. Radiology department, Hospital Clínic de Barcelona. IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jordi Bruix
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
| | - María Reig
- BCLC group. Liver Unit, Hospital Clínic de Barcelona. IDIBAPS. CIBERehd, University of Barcelona, Barcelona, Spain
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Díaz-González Á, Sanduzzi-Zamparelli M, Sapena V, Torres F, LLarch N, Iserte G, Forner A, da Fonseca L, Ríos J, Bruix J, Reig M. Systematic review with meta-analysis: the critical role of dermatological events in patients with hepatocellular carcinoma treated with sorafenib. Aliment Pharmacol Ther 2019; 49:482-491. [PMID: 30695819 DOI: 10.1111/apt.15088] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 09/26/2018] [Accepted: 11/19/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Álvaro Díaz-González
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - Marco Sanduzzi-Zamparelli
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - Víctor Sapena
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - Ferran Torres
- Medical Statistics Core Facility, IDIBAPS, Hospital Clinic Barcelona & Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Neus LLarch
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - Gemma Iserte
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - Alejandro Forner
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - Leonardo da Fonseca
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - José Ríos
- Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) and Hospital Clinic, Barcelona, Spain.,Biostatistics Unit, Faculty of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Bruix
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
| | - María Reig
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic de Barcelona, IDIBAPS, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Universidad de Barcelona, Barcelona, Spain
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Reig M, Torres F, Rodriguez-Lope C, Forner A, LLarch N, Rimola J, Darnell A, Ríos J, Ayuso C, Bruix J. Early dermatologic adverse events predict better outcome in HCC patients treated with sorafenib. J Hepatol 2014; 61:318-24. [PMID: 24703956 DOI: 10.1016/j.jhep.2014.03.030] [Citation(s) in RCA: 186] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 02/27/2014] [Accepted: 03/24/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS There are no clinical data/markers to predict improved survival in patients with hepatocellular carcinoma treated with sorafenib. Majority of sorafenib adverse events appear within the first 60 days of treatment and studies correlating them with outcome are needed. METHODS We prospectively studied 147 hepatocellular carcinoma patients (97% cirrhotic, 82% Child-Pugh A, BCLC-B 77, BCLC-C 69) treated with sorafenib. Follow-up included monthly clinical and laboratory monitoring and tumor staging at week 4 and every 8 weeks. RESULTS After a median follow up of 11.6 months (treatment duration 6.7 months), time to progression and overall survival were 5.1 and 12.7 months. All but one patient presented at least one adverse event (median time to appearance 56 days). Time dependent covariate analysis (HR [95% CI]) identified baseline performance status (2.86 [1.75 to 4.55], p<0.001), BCLC (1.69 [1.18 to 2.50], p = 0.005), and dermatologic adverse event requiring dose adjustment within the first 60 days (0.58 [0.36 to 0.92], p = 0.022) as independent predictors of better outcome. Other early adverse events did not have an impact in outcome. The predictive value of dermatologic adverse events for survival was confirmed by the landmark analysis (p = 0.0270). CONCLUSIONS Development of dermatologic adverse events within 60 days of sorafenib initiation is associated with better survival. Therefore, this should not to be taken as a negative event and discourage treatment maintenance. Likewise, second line clinical trials should be designed and/or evaluated considering this information to avoid significant bias.
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Affiliation(s)
- Maria Reig
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Ferran Torres
- Biostatistics and Data Management Core Facility, IDIBAPS, Hospital Clínic Barcelona, Spain; Biostatistics Unit, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Rodriguez-Lope
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Alejandro Forner
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Neus LLarch
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Jordi Rimola
- Barcelona Clinic Liver Cancer (BCLC) Group, Radiology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Anna Darnell
- Barcelona Clinic Liver Cancer (BCLC) Group, Radiology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - José Ríos
- Biostatistics and Data Management Core Facility, IDIBAPS, Hospital Clínic Barcelona, Spain; Biostatistics Unit, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carmen Ayuso
- Barcelona Clinic Liver Cancer (BCLC) Group, Radiology Department, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Jordi Bruix
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
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