Comparison of survival benefit between salvage surgery after conversion therapy versus surgery alone for hepatocellular carcinoma with portal vein tumor thrombosis: a propensity score analysis

Hepatic artery infusion chemotherapy combined with camrelizumab and apatinib as conversion therapy for patients with unresectable hepatocellular carcinoma: a single-arm exploratory trial

BACKGROUND

The development of systemic therapy, including targeted drugs and immune checkpoint inhibitors, has significantly improved the prognosis of patients with advanced unresectable hepatocellular carcinoma (uHCC). Hepatic arterial infusion chemotherapy (HAIC) has been gradually applied to the treatment of advanced uHCC, showing good potential as conversion therapy. We aimed to investigate the efficacy and safety of HAIC combined with camrelizumab and apatinib as conversion therapy for uHCC.

METHODS

This study was a single-arm exploratory trial (NCT05099848) in patients with uHCC. Eligible patients received apatinib 250 mg once daily, camrelizumab 200 mg on day 3, and HAIC with FOLFOX regimen (oxaliplatin 85 mg/m2 at hours 0-2, leucovorin 400 mg/m2 at hours 2-3, and fluorouracil 400 mg/m2 at hour 3, followed by fluorouracil 2400 mg/m2 for 46 h) on days 4-5 of each 21-day cycle for up to 8 cycles. Primary endpoints were conversion rate and margin-free (R0) resection rate.

RESULTS

Between March 2021 and July 2023, 19 patients were enrolled. Median follow-up was 14.9 months (interquartile range, 10.9-21.1). Disease became resectable in 14 (73.7%) of 19 patients; nine (47.4%) patients received R0 resection, while five (26.3%) refused surgery and opted for observation. Three (33.3%) of nine patients with surgery achieved major pathological response, including two (22.2%) with pathological complete response. Objective response and disease control rates were 47.4% (9/19) and 89.5% (17/19) per Response Evaluation Criteria In Solid Tumors (RECIST) version 1.1 and both 89.5% (17/19) per modified RECIST. Survival data were immature. Fourteen (73.7%) of 19 patients had grade 3 or higher treatment-related adverse events, with the most common being increased alanine aminotransferase or aspartate aminotransferase (seven [36.8%]) and increased lymphocyte count (six [31.6%]). No treatment-related deaths occurred.

CONCLUSIONS

The combination of HAIC, camrelizumab, and apatinib as conversion therapy shows promising clinical benefits and a manageable safety profile in patients with uHCC. Future randomized controlled trials are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05099848. Registered on October 13, 2021.

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.

Prognostic factors and clinical significance of preoperative systemic therapy in patients with borderline resectable hepatocellular carcinoma: A JSHBPS project study 2023, Part 2

PURPOSE

To explore factors influencing the prognosis in patients with borderline-resectable hepatocellular carcinoma (BR-HCC) undergoing surgery.

METHODS

The clinical data of patients with BR-HCC according to the definition in the Expert Consensus Statement 2023 were collected from board-certified HPB training centers and analyzed in detail.

RESULTS

Data of a total of 1509 patients with BR-HCC (BR1, n = 718 and BR2, n = 791) who underwent surgery were collected. The 5-year disease-specific survival rate (DSS) and 3-year recurrence-free survival rate (RFS) were determined as 40.8% and 19.7%, respectively. Multivariate analysis identified the oncological resectability category (i.e., BR2 vs. BR1) as a significant prognostic factor, and also the number of criteria fulfilled for classification into BR2 disease as being predictive of the DSS (hazard ratio (HR) [95% CI]: one factor: 1.32 [1.13-1.54]; two to three factors: 1.51 [1.15-1.96]). Preceding systemic therapy was significantly correlated with a longer DSS (HR, 0.41: 95% CI, 0.18-0.91) and RFS (HR, 0.80: 95% CI, 0.66-0.97) in the patients with BR1 disease, while its clinical significance was unclear in the patients with BR2 disease.

CONCLUSION

Multicenter data confirm the clinical relevance of the oncological resectability category and the potential advantage of preceding systemic therapy in a specific group of BR-HCC.

Precision surgery for hepatocellular carcinoma

Hepatocellular carcinoma arises in the setting of cirrhosis in most cases, requiring multidisciplinary input to define resectability. In this regard, more precise surgical management considers patient factors and anatomical states, including resection margins, tumour biology, and perioperative therapy. Together with advances in surgical techniques, this integrated approach has resulted in considerable improvements in patient morbidity and oncological outcomes. Despite this, recurrence rates in hepatocellular carcinoma remain high. As the systemic treatment landscape in hepatocellular carcinoma continues to evolve and locoregional options are increasingly used, we review current and future opportunities to individualise the surgical management of patients with hepatocellular carcinoma.

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.

Systemic conversion therapies for initially unresectable hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Systemic conversion therapy provides patients with initially unresectable hepatocellular carcinoma (HCC) the chance to salvage radical liver resection and superior survival outcomes, but the optimal conversion strategy is unclear.

METHODS

A systematic literature search was conducted on PubMed, EMBASE, Web of Science, Scopus, and the Cochrane Library between 2007 and 2024 focusing on studies reporting conversion therapy for HCC. The treatment groups were divided into Tyrosine kinase inhibitors (TKI), TKI plus loco-regional therapy (LRT), TKI plus anti-PD-1 therapy (TKI + PD-1), TKI + PD-1 + LRT, immune checkpoint inhibitors (ICI) plus LRT, and Atezolizumab plus bevacizumab (A + T) groups. The conversion to surgery rate (CSR), objective response rate (ORR), grade ≥ 3 treatment-related adverse events (AEs), overall survival (OS) and progression-free survival (PFS) were analyzed.

RESULTS

38 studies and 4,042 patients were included. The pooled CSR were 8% (95% CI, 5-12%) in TKI group, 13% (95% CI, 8-19%) in TKI + LRT group, 28% (95% CI, 19-37%) in TKI + PD-1 group, 33% (95% CI, 25-41%) in TKI + PD-1 + LRT group, 23% (95% CI, 1-46%) in ICI + LRT group, and 5% (95% CI, 3-8%) in A + T group, respectively. The pooled HR for OS (0.45, 95% CI, 0.35-0.60) and PFS (0.49, 95% CI, 0.35-0.70) favored survival benefit of conversion surgery. Subgroup analysis revealed that lenvatinib + PD-1 + LRT conferred higher CSR of 35% (95% CI, 26-44%) and increased ORR of 70% (95% CI, 56-83%).

CONCLUSIONS

The current study indicates that TKI + PD-1 + LRT, especially lenvatinib + PD-1 + LRT, may be the superior conversion therapy with a manageable safety profile for patients with initially unresectable HCC. The successful conversion therapy favors the superior OS and PFS compared with systemic treatment alone.

TRIAL REGISTRATION

International prospective register of systematic reviews (PROSPERO) (registration code: CRD 42024495289).

Chinese expert consensus on refined diagnosis, treatment, and management of advanced primary liver cancer (2023 edition)

Hepatocellular carcinoma (HCC), commonly known as primary liver cancer, is a major cause of malignant tumors and cancer-related deaths in China, accounting for approximately 85% of all cancer cases in the country. Several guidelines have been used to diagnose and treat liver cancer. However, these guidelines provide a broad definition for classifying advanced liver cancer, with an emphasis on a singular approach, without considering treatment options for individual patients. Therefore, it is necessary to establish a comprehensive and practical expert consensus, specifically for China, to enhance the diagnosis and treatment of HCC using the Delphi method. The classification criteria were refined for Chinese patients with HCC, and the corresponding optimal treatment regimen recommendations were developed. These recommendations took into account various factors, including tumor characteristics, vascular tumor thrombus grade, distant metastasis, liver function status, portal hypertension, and the hepatitis B virus replication status of patients with primary HCC, along with treatment prognosis. The findings and recommendations provide detailed, scientific, and reasonable individualized diagnosis and treatment strategies for clinicians.

Comparison of survival benefit and safety between surgery following conversion therapy versus surgery alone in patients with surgically resectable hepatocellular carcinoma at CNLC IIb/IIIa stage: a propensity score matching study

OBJECTIVE

The objective of this study is to evaluate and compare the survival benefit and safety of surgery following conversion therapy versus surgery alone in patients diagnosed with surgically resectable hepatocellular carcinoma (HCC) at China Liver Cancer Staging (CNLC) IIb/IIIa stage.

METHODS

A total of 95 patients diagnosed with surgically resectable CNLC IIb/IIIa HCC were retrospectively enrolled in our study from November 2018 to December 2022. Among them, 30 patients underwent conversion therapy followed by hepatectomy, while the remaining 65 received surgery alone. The primary endpoint was recurrence-free survival (RFS). Propensity score matching was employed to minimize bias in the retrospective analysis.

RESULTS

Compared to the surgery alone group, the conversion therapy group demonstrated a significantly prolonged median RFS (17.1 vs. 7.0 months; P =0.014), a reduced incidence of microvascular invasion (MVI, 23.3 vs. 81.5%; P <0.001), and a comparable rate of achieving Textbook Outcome in Liver Surgery (TOLS, 83.3 vs. 76.9%; P =0.476). Multivariate analysis indicated that conversion therapy was independently associated with improved RFS after hepatectomy (HR=0.511, P =0.027). The same conclusions were obtained after propensity score matching.

CONCLUSIONS

The findings of our study offer preliminary evidence that preoperative conversion therapy significantly prolongs RFS in patients with surgically resectable HCC at CNLC IIb/IIIa stage. Furthermore, combining conversion therapy and hepatectomy represents a relatively safe treatment strategy.

Serum alpha-fetoprotein response as a preoperative prognostic indicator in unresectable hepatocellular carcinoma with salvage hepatectomy following conversion therapy: a multicenter retrospective study

BACKGROUND

This study evaluates the efficacy of alpha-fetoprotein (AFP) response as a surrogate marker for determining recurrence-free survival (RFS) in patients with unresectable hepatocellular carcinoma (uHCC) who undergo salvage hepatectomy following conversion therapy with tyrosine kinase inhibitor (TKI) and anti-PD-1 antibody-based regimen.

METHODS

This multicenter retrospective study included 74 patients with uHCC and positive AFP (>20 ng/mL) at diagnosis, who underwent salvage hepatectomy after treatment with TKIs and anti-PD-1 antibody-based regimens. The association between AFP response-defined as a ≥ 80% decrease in final AFP levels before salvage hepatectomy from diagnosis-and RFS post-hepatectomy was investigated.

RESULTS

AFP responders demonstrated significantly better postoperative RFS compared to non-responders (P<0.001). The median RFS was not reached for AFP responders, with 1-year and 2-year RFS rates of 81.3% and 70.8%, respectively. In contrast, AFP non-responders had a median RFS of 7.43 months, with 1-year and 2-year RFS rates at 37.1% and 37.1%, respectively. Multivariate Cox regression analysis identified AFP response as an independent predictor of RFS. Integrating AFP response with radiologic tumor response facilitated further stratification of patients into distinct risk categories: those with radiologic remission experienced the most favorable RFS, followed by patients with partial response/stable disease and AFP response, and the least favorable RFS among patients with partial response/stable disease but without AFP response. Sensitivity analyses further confirmed the association between AFP response and improved RFS across various cutoff values and in patients with AFP ≥ 200 ng/mL at diagnosis (all P<0.05).

CONCLUSION

The "20-80" rule based on AFP response could be helpful for clinicians to preoperatively stratify the risk of patients undergoing salvage hepatectomy, enabling identification and management of those unlikely to benefit from this procedure.