Conversion therapy for advanced hepatocellular carcinoma with vascular invasion: a comprehensive review

A Survey of Clinical Practices for Hepatocellular Carcinoma Among Experts at Tertiary Hospitals in China From 2020 to 2021

Background

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related death in China. The rapid progress in systemic therapies has led to the approval of many therapeutic methods that have quickly changed clinical guidelines and practices. Because of the high heterogeneity of HCC, there are still some gaps between the guidelines and real-world clinical practice. The present study surveyed experts in China to investigate the current treatment concepts and clinical practice regarding HCC.

Methods

A questionnaire survey on the treatment concepts and clinical practice of HCC was administered to 310 experts with senior professional titles in 2020 and 312 experts in 2021. The results were analyzed and compared.

Results

For treating patients with resectable HCC, 28% of hepatobiliary surgeons indicated neoadjuvant therapy, and 7% chose systemic therapy ± locoregional therapy as 1 L therapy in 2021 compared with 20% and 1% in 2020. More experts chose adjuvant treatment within 1 month in 2021 compared with 2020, and 6 months and 12 months were the leading choices for the duration of adjuvant treatment. In 2021, 79% of surgeons and 19% of interventionalists were willing to conduct downstaging/conversion therapy for patients with potentially resectable HCC, and 78% chose tyrosine kinase inhibitors (TKI) + immunotherapy (IO) + locoregional therapy for cases in which R0 resection could not be achieved. For completely unresectable HCC, more experts preferred TKI + IO-based therapy as 1 L therapy in 2021 compared with 2020 (78% vs. 55%). The proportion of experts who indicated TKI + IO-based therapy as 2 L therapy increased from 32% in 2020 to 40% in 2021.

Conclusion

The survey results indicated that in 2021, compared with 2020, more experts opted to administer IO + TKI for the treatment of liver cancer, and more experts and patients were willing to participate in clinical research.

The effectiveness and safety of therapies for hepatocellular carcinoma with tumor thrombus in the hepatic vein, inferior vena cave and/or right atrium: a systematic review and single-arm meta-analysis

BACKGROUND

This review evaluates the efficacy and safety of therapies for hepatocellular carcinoma (HCC) with hepatic vein tumor thrombus (HVTT), inferior vena cava tumor thrombus (IVCTT), and/or right atrium tumor thrombus (RATT).

RESEARCH DESIGN AND METHODS

A systematic review of PubMed, EMBASE, Cochrane Library, and Wanfang databases up to 22 August 2024, was conducted, focusing on overall survival (OS), progression -free survival (PFS), and adverse reactions.

RESULTS

Seven studies involving 453 patients were analyzed. Treatment strategies included surgery alone, local ± systemic therapy, and surgery with adjuvant therapy. The pooled 1-, 3-, and 5-year OS rates for all patients were 63.3%, 21.6% , and 8.3%, respectively. Surgery with adjuvant therapy achieved the highest 1-year OS, while local ± systemic therapy led to the best 5-year OS. The pooled 1-, 3-, and 5-year PFS rates for all patients were 56.8%, 9.4%, and 1.6%, respectively. Surgery alone commonly caused ascites and pleural effusion; the local ± systemic therapy commonly caused hepatic dysfunction and platelet abnormalities; and surgery with adjuvant therapy commonly caused peritoneal abscess.

CONCLUSION

Local ± systemic therapy provided the best long-term OS and manageable complications among the therapeutic strategies for HCC with HVTT, IVCTT, and/or RATT.

REGISTRATION

PROSPERO, (CRD42024573152).

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.

Community characteristics and relationship between gut microbiota and intratumoral microbiota in hepatocellular carcinoma

Background

The combination of local therapy with lenvatinib and programmed cell death protein-1 (PD-1) inhibitors represents an emerging treatment paradigm for unresectable hepatocellular carcinoma (uHCC). Our study sought to investigate the interrelationship between gut microbiota and intratumoral microbiota in the context of triple therapy, with a view to identifying potential biological markers.

Methods

The gut microbial community profiles of patients with primary untreated hepatocellular carcinoma (HCC) and those treated with local therapy combined with lenvatinib and PD-1 inhibitors were analyzed by 16S rRNA gene amplicon sequencing. Additionally, microbial community profiles of tumor tissues of patients with HCC and normal liver tissues were analyzed.

Results

In our investigation, we observed that patients with HCC who received triple therapy exhibited a notable enhancement in the abundance of Actinobacteriota and a considerable decrease in Escherichia Shigella. Patients who received hepatic artery infusion chemotherapy (HAIC) in combination with levatinib and PD-1 inhibitors exhibited significantly elevated levels of Faecalibacterium prausnitzii and Bacteroides stercoris in comparison to those who received transarterial chemoembolization (TACE) in combination with levatinib and PD-1 inhibitors. Furthermore, a notable decline in microbial diversity was observed within HCC tumors in comparison to normal liver tissues. The gut and intratumoral microbiota in HCC patients exhibited a high degree of similarity to the microbes present at the phylum level.

Conclusions

Gut microbiota is connected to triple therapy with local therapy combined with lenvatinib and PD-1 inhibitors for HCC. These discoveries underscore the potential of utilizing gut microbiota and intratumoral microbiota as biomarkers, as well as the possibility of triple therapy in the management of HCC.

Conversion therapy for hepatocellular carcinoma to improve treatment strategies for intermediate and advanced stages

This manuscript is based on a case reported by Song et al published in the World Journal of Clinical Cases. Several challenges remain in the field of hepatocellular carcinoma (HCC) conversion therapy. Consequently, only a limited number of patients with HCC accompanied by portal vein tumor thrombosis (PVTT) and hepatic vein tumor thrombosis (HVTT) are eligible for resection. This clinical case demonstrates that considering the complexity of the disease, a multimodal and multidisciplinary approach is essential for managing HCC accompanied by PVTT and HVTT. However, the outcomes of such surgeries remain controversial. In conclusion, research on HCC conversion therapy is extremely useful for improving treatment strategies for intermediate and advanced HCC, which currently have disappointing clinical outcomes.

Lenvatinib‑based treatment regimens in conversion therapy of unresectable hepatocellular carcinoma: A systematic review and meta‑analysis

Hepatocellular carcinoma (HCC) is a malignancy associated with high morbidity and mortality rates. Conversion therapy provides patients with unresectable HCC (uHCC) the opportunity to undergo radical treatment and achieve long-term survival. Despite accumulating evidence regarding the efficacy of conversion therapy, the optimal treatment approach for such therapy remains uncertain. Lenvatinib (LEN) has shown efficacy and tolerable rates of adverse events (AEs) when applied in combination with immune checkpoint inhibitors (ICIs) or locoregional therapy (LRT) over the past decade. Therefore, the present meta-analysis was performed to systematically assess the safety and efficacy of LEN-based treatment regimens in conversion therapies for uHCC. Data on outcomes, including the conversion rate, objective response rate (ORR), disease control rate (DCR) and AE incidence in patients with uHCC, were collected. A systematic literature search was performed using MEDLINE, Embase, Web of Science and Cochrane Library databases, up to the date of September 1, 2023. In total, 16 studies, encompassing a total of 1,650 cases of uHCC, were included in the final meta-analysis. The pooled conversion rates for LEN alone, LEN + ICI, LEN + LRT and LEN + ICI + LRT were calculated to be 0.04 (95% CI, 0.00-0.07; I2=77%), 0.23 (95% CI, 0.16-0.30; I2=66%), 0.14 (95% CI, 0.10-0.18; I2=0%) and 0.35 (95% CI, 0.23-0.47; I2=88%), respectively. The pooled ORRs for LEN alone, LEN + ICI, LEN + LRT and LEN + ICI + LRT were found to be 0.45 (95% CI, 0.23-0.67; I2=96%), 0.49 (95% CI, 0.39-0.60; I2=78%), 0.43 (95% CI, 0.24-0.62; I2=88%) and 0.69 (95% CI, 0.56-0.82; I2=92%), respectively. The pooled DCRs for LEN alone, LEN + ICI, LEN + LRT and LEN + ICI + LRT were observed to be 0.77 (95% CI, 0.73-0.81; I2=23%), 0.82 (95% CI, 0.69-0.95; I2=90%), 0.67 (95% CI, 0.39-0.94; I2=94%) and 0.87 (95% CI, 0.82-0.93; I2=67%), respectively. The pooled grade ≥3 AEs for LEN alone, LEN + ICI, LEN + LRT and LEN + ICI + LRT were 0.25 (95% CI, 0.14-0.36; I2=89%), 0.43 (95% CI, 0.34-0.53; I2=23%), 0.42 (95% CI, 0.19-0.66; I2=81%) and 0.35 (95% CI, 0.17-0.54; I2=94%), respectively. These findings suggested that LEN-based combination strategies may confer efficacy and acceptable tolerability for patients with uHCC. In particular, LEN + ICI, with or without LRT, appears to represent a highly effective conversion regimen, with an acceptable conversion rate and well-characterized safety profile.