Hepatocyte growth factor/MET inhibitors
The mesenchymal–epithelial transition (MET) factor receptor is dysregulated in HCC. Tivantinib is a selective oral MET inhibitor with a tolerable safety profile that demonstrated initial efficacy against HCC in tumors with high MET expression.37,41 Unfortunately, in the randomized, placebo-controlled METIV-HCC Phase III trial, tivantinib did not improve PFS or OS as second-line therapy for patients with MET high HCC.42
Given the highly vascular nature of HCC and high levels of VEGF expression, multiple other agents that target the VEGF pathway have been evaluated in HCC. These agents consistently demonstrate some clinical activity, but fewer patients seem to derive benefit from drugs targeting VEGF alone compared to VEGF pathway inhibitors used in combination with other targets.
Bevacizumab, an anti-VEGF monoclonal antibody, has shown activity as a single agent and in combination with other drugs in HCC. A small Phase II study of bevacizumab in 46 patients with liver-confined HCC, good performance status and compensated liver disease demonstrated a PFS of 65% at 6 months and objective response in six patients (13%; 95% CI=3%–23%). Median PFS time was found to be 6.9 months (95% CI, 6.5–9.1 months), and OS was found to be 53% at 1 year, 28% at 2 years, and 23% at 3 years. The most commonly recorded clinically significant adverse events included hypertension, thrombosis, and hemorrhage, including one fatal variceal bleed.43
Bevacizumab has also been studied in combination with other therapies. A small Phase II trial combining bevacizumab with GEMOX showed a median OS of 9.6 months and median PFS of 5.3 months. The most common treatment-related grade 3 to 4 toxicities recorded were leukopenia/neutropenia, transient elevation of aminotransferases, hypertension, and fatigue.44 While this study demonstrated the safety and efficacy of the combination of bevacizumab and GEMOX, it is unclear whether the combination is better than bevacizumab or GEMOX given alone. Another Phase II trial combining bevacizumab with oxaliplatin and capecitabine showed a median PFS of 6.8 months and median OS of 9.8 months. Eight patients (20%) achieved partial response and 23 patients (58%) had stable disease, conferring an overall disease control rate of 77.5%. The combination therapy was generally well tolerated with limited grade 3/4 toxicity recorded; the toxicities were mainly peripheral neurotoxicity and fatigue.45 A Phase II study of bevacizumab with erlotinib showed a median time to progression of 3.9 months and median OS of 9.9 months.46 The consensus of the National Comprehensive Cancer Network (NCCN) at this time is that there are insufficient data to support the use of bevacizumab in patients with HCC.6
Sunitinib, another nonspecific TKI which targets the VEGFRs amongst other pathways, failed to show significant efficacy in HCC. A large, randomized Phase III study comparing sunitinib and sorafenib was terminated early for futility and safety reasons.31 Axitinib, a second-generation TKI that targets VEGFRs, has been studied in a randomized Phase II trial of patients with advanced HCC with progression or intolerance of sorafenib. This study compared best supportive care plus axitinib versus placebo, and found no significant difference in median OS.47
Ramucirumab is a recombinant monoclonal antibody that inhibits the VEGFR. A Phase III trial of patients previously treated with sorafenib failed to show significant improvement in OS over placebo (9.2 versus 7.6 months; HR=0.87, 95% CI=0.72–1.05; P=0.14), but it did show improvement in median PFS (2.8 versus 2.1 months; HR=0.63, 95% CI=0.52–0.75; P<0.001) and time to tumor progression (3.5 versus 2.6 months; HR=0.59; 95% CI=0.49–0.72; P<0.001). Unplanned subset analysis suggested the potential for a survival benefit in patients with a high initial level of alpha-fetoprotein (AFP, >400 ng/mL) at diagnosis,34 and a follow-up Phase III study among patients with elevated baseline AFP is currently underway (NCT02435433).
Epidermal growth factor receptor (EGFR) and ligand expression is frequently seen in HCC; however, neither EGFR TKIs nor monoclonal antibodies have demonstrated benefit against HCC. Erlotinib, an oral TKI with specificity for EGFR, offers some modest control over HCC as demonstrated in two Phase II studies investigating first-line use of the drug.48,49 Its efficacy in combination with bevacizumab has been studied with conflicting results.50,51 In an ongoing randomized Phase II trial, investigators are studying how bevacizumab in combination in comparison to sorafenib as the first-line therapy (NCT00881751). Erlotinib combined with sorafenib was assessed in a randomized Phase III trial and showed no significant improvement in OS compared to sorafenib with placebo. In addition, in patients receiving erlotinib and sorafenib, the disease control rate was significantly lower (43.9% versus 52.5%; P=0.021).33
When studied in a Phase II trial, cetuximab, a chimeric monoclonal antibody that binds specifically to EGFR, was generally well tolerated but showed no antitumor activity in HCC.52 Cetuximab has been combined with capecitabine and oxaliplatin53 and GEMOX54 in single arm Phase II trials with disappointing results.
Other targeted therapies
The mechanistic target of rapamycin (mTOR) is a central regulator of cell growth and angiogenesis, and the mTOR pathway is activated in 40%–50% of the patients with HCC.55 Based on early promise in the Phase II setting, everolimus (an mTOR inhibitor) was studied in a large Phase III trial of patients with progression or intolerance to sorafenib. This study showed no improvement in OS over placebo.36
Fibroblast growth factor (FGF) proteins are involved in tumor growth and angiogenesis in HCC and are thought to play a role in relapse with sorafenib through evasion of VEGF blockade. Brivanib is a selective dual inhibitor of FGF and VEGF receptor tyrosine kinases. The Phase III BRISK-PS trial evaluated the efficacy and safety of brivanib in patients with advanced HCC who had intolerance to or progression on or after sorafenib. Brivanib did not significantly improve median OS compared to placebo (9.4 versus 8.2 months, HR=0.89; 95.8% CI=0.69–1.15; P=0.3307).35 Other studies are underway to determine whether FGF receptor inhibitors have greater efficacy in selected patients with FGF amplification (NCT02421185, NCT02508467, and NCT03144661).
Without a doubt, immuno-oncology is the most exciting new therapeutic arena in HCC. There is a substantial body of evidence that supports the rationale for the use of immune-based approaches to treat HCC.56 This theoretical rationale is now supported by evidence that multiple checkpoint inhibitors are active in advanced HCC.
Some of the earliest data on immunotherapy came from a Phase II study of the CTLA-4 inhibitor tremelimumab in patients with chronic HCV and advanced HCC. In this small study, tremelimumab resulted in a response rate of 18%, a disease control rate of 76%, and a median OS of 8.2 months.57More recently, the large Phase I/II CheckMate 040 study of nivolumab, a human monoclonal antibody inhibitor of programmed death-1 (PD-1), has shown that nivolumab has robust activity in advanced HCC. This study included 262 patients with unselected PD-L1 tumors—both treatment naïve patients and those who had received one prior line of therapy, usually sorafenib. Following confirmation of safety and tolerability in the dose-escalation phase, all patients in the dose-expansion phase received intravenous nivolumab 3 mg/kg every 2 weeks until disease progression or limiting toxicity. The overall objective response rate was 15% (95% CI=6–28) in the dose-escalation phase, including three complete responses and four partial responses, and 20% (95% CI=15–26) in patients treated with nivolumab 3 mg/kg in the dose-expansion phase. Notably, responses were observed regardless of PD-L1 expression on tumor cells, and typically occurred within 3 months of treatment initiation. Median OS was found to be 28.8 months in the sorafenib naïve group, and 15.6 months in the sorafenib-treated group.58 The most common grade 3 or 4 treatment-related adverse events consisted of increased levels of aspartate aminotransferase (4%) and alanine aminotransferase (2%), without any evidence of clinical repercussions. Symptomatic treatment-related adverse events were comparable in patients with and without viral hepatitis infection.58 The Phase III CheckMate 459 trial is currently underway and aims to compare nivolumab and sorafenib as first-line therapy in patients with advanced HCC (NCT02576509).
In addition to nivolumab, multiple other immune checkpoint inhibitors are being evaluated in HCC. For example, durvalumab (anti-PDL1) has shown comparable response rates and duration of disease control as nivolumab in a small Phase I/II trial.59 The Phase III KEYNOTE-240 study is an ongoing randomized, double blind, placebo controlled study of pembrolizumab versus placebo in patients with sorafenib refractory/intolerance advanced HCC (NCT02702401). Combination CTLA-4 and PD-1/PDL-1 inhibitor trials are also ongoing with durvalumab/tremelimumab (NCT02519348) as well as nivolumab/ipilimumab (Checkmate 040, NCT01658878).
Challenges and opportunities for treatment of HCC
HCC remains one of the leading causes of cancer-related deaths around the world, and there is an unmet need for systemic therapies to effectively and safely treat patients with this cancer. While we are beginning to see some promise of improved therapeutic options (summarized in Table 2), a great need for further investigation exists. We strongly encourage all patients with advanced HCC to participate in clinical trials. The complexity of this disease underscores the importance of a multidisciplinary clinical approach and a multi-faceted research approach encompassing clinical providers, clinical and basic science researchers, and public health leaders. While optimal therapy for second-line treatment of HCC remains unclear, we anticipate promising therapies on the horizon that will only be possible through the willing participation of both patients and providers in investigation of new therapies.
The authors report no conflicts of interest in this work.
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Source: Journal of Hepatocellular Carcinoma.
Originally published November 8, 2017.