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Yang H, Kang B, Ha Y, Lee SH, Kim I, Kim H, Lee WS, Kim G, Jung S, Rha SY, Gaillard VE, Cheon J, Kim C, Chon HJ. High serum IL-6 correlates with reduced clinical benefit of atezolizumab and bevacizumab in unresectable hepatocellular carcinoma. JHEP Rep 2023; 5:100672. [PMID: 36866388 PMCID: PMC9972403 DOI: 10.1016/j.jhepr.2023.100672] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [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: 10/02/2022] [Revised: 12/22/2022] [Accepted: 12/24/2022] [Indexed: 01/18/2023] Open
Abstract
Background & Aims We elucidated the clinical and immunologic implications of serum IL-6 levels in patients with unresectable hepatocellular carcinoma (HCC) treated with atezolizumab and bevacizumab (Ate/Bev). Methods We prospectively enrolled 165 patients with unresectable HCC (discovery cohort: 84 patients from three centres; validation cohort: 81 patients from one centre). Baseline blood samples were analysed using a flow cytometric bead array. The tumour immune microenvironment was analysed using RNA sequencing. Results In the discovery cohort, clinical benefit 6 months (CB6m) was defined as complete or partial response, or stable disease for ≥6 months. Among various blood-based biomarkers, serum IL-6 levels were significantly higher in participants without CB6m than in those with CB6m (mean 11.56 vs. 5.05 pg/ml, p = 0.02). Using maximally selected rank statistics, the optimal cut-off value for high IL-6 was determined as 18.49 pg/ml, and 15.2% of participants were found to have high IL-6 levels at baseline. In both the discovery and validation cohorts, participants with high baseline IL-6 levels had a reduced response rate and worse progression-free and overall survival after Ate/Bev treatment compared with those with low baseline IL-6 levels. In multivariable Cox regression analysis, the clinical implications of high IL-6 levels persisted, even after adjusting for various confounding factors. Participants with high IL-6 levels showed reduced interferon-γ and tumour necrosis factor-α secretion from CD8+ T cells. Moreover, excess IL-6 suppressed cytokine production and proliferation of CD8+ T cells. Finally, participants with high IL-6 levels exhibited a non-T-cell-inflamed immunosuppressive tumour microenvironment. Conclusions High baseline IL-6 levels can be associated with poor clinical outcomes and impaired T-cell function in patients with unresectable HCC after Ate/Bev treatment. Impact and implications Although patients with hepatocellular carcinoma who respond to treatment with atezolizumab and bevacizumab exhibit favourable clinical outcomes, a fraction of these still experience primary resistance. We found that high baseline serum levels of IL-6 correlate with poor clinical outcomes and impaired T-cell response in patients with hepatocellular carcinoma treated with atezolizumab and bevacizumab.
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Key Words
- AFP, alpha-foetoprotein
- Ate/Bev, atezolizumab and bevacizumab
- Atezolizumab
- BCLC, Barcelona Clinic Liver Cancer
- Bevacizumab
- CB6m, clinical benefit 6 months
- CONSORT, Consolidated Standards of Reporting Trials
- CR, complete response
- CRAFITY, C-reactive protein and AFP in immunotherapy
- CTLA-4, cytotoxic T-lymphocyte-associated protein 4
- DC, dendritic cell
- ECOG, Eastern Cooperative Oncology Group
- FFPE, formalin-fixed paraffin-embedded
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- Hepatocellular carcinoma
- IFN-γ, interferon-γ
- IL-6
- Immunotherapy
- MDSC, myeloid-derived suppressor cell
- MSI, microsatellite instability
- MVI, macrovascular invasion
- ORR, objective response rate
- OS, overall survival
- PBMC, peripheral blood mononuclear cell
- PD, progressive disease
- PD-1, programmed-death-1
- PD-L1, programmed-death ligand-1
- PFS, progression-free survival
- PR, partial response
- RECIST, Response Evaluation Criteria in Solid Tumours
- SD, stable disease
- TME, tumour microenvironment
- TNF-α, tumour necrosis factor-α
- VEGF, vascular endothelial growth factor
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Affiliation(s)
- Hannah Yang
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Beodeul Kang
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea,Yonsei Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yeonjung Ha
- Department of Gastroenterology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Sung Hwan Lee
- Department of Surgery, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Ilhwan Kim
- Division of Oncology, Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, Republic of Korea
| | - Hyeyeong Kim
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Won Suk Lee
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Gwangil Kim
- Department of Pathology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Sanghoon Jung
- Department of Radiology, CHA Bundang Medical Center, Seongnam, Republic of Korea
| | - Sun Young Rha
- Yonsei Graduate School, Yonsei University College of Medicine, Seoul, Republic of Korea,Division of Medical Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | | | - Jaekyung Cheon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea,Corresponding authors. Address: Medical Oncology, CHA Bundang Medical Center, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Republic of Korea. Tel.: +82-31-780-7590; Fax: +82-31-780-3929.
| | - Chan Kim
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea,Corresponding authors. Address: Medical Oncology, CHA Bundang Medical Center, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Republic of Korea. Tel.: +82-31-780-7590; Fax: +82-31-780-3929.
| | - Hong Jae Chon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea,Corresponding authors. Address: Medical Oncology, CHA Bundang Medical Center, 59 Yatap-ro, Bundang-gu, Seongnam 13496, Republic of Korea. Tel.: +82-31-780-7590; Fax: +82-31-780-3929.
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Kudo M, Galle PR, Brandi G, Kang YK, Yen CJ, Finn RS, Llovet JM, Assenat E, Merle P, Chan SL, Palmer DH, Ikeda M, Yamashita T, Vogel A, Huang YH, Abada PB, Yoshikawa R, Shinozaki K, Wang C, Widau RC, Zhu AX. Effect of ramucirumab on ALBI grade in patients with advanced HCC: Results from REACH and REACH-2. JHEP Rep 2020; 3:100215. [PMID: 33392490 PMCID: PMC7772786 DOI: 10.1016/j.jhepr.2020.100215] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 08/07/2020] [Revised: 10/06/2020] [Accepted: 10/19/2020] [Indexed: 02/08/2023] Open
Abstract
Background & Aims The albumin–bilirubin (ALBI) grade/score is derived from a validated nomogram to objectively assess prognosis and liver function in patients with hepatocellular carcinoma (HCC). In this post hoc analysis, we assessed prognosis in terms of survival by baseline ALBI grade and monitored liver function during treatment with ramucirumab or placebo using the ALBI score in patients with advanced HCC. Methods Patients with advanced HCC, Child-Pugh class A with prior sorafenib treatment were randomised in REACH trials to receive ramucirumab 8 mg/kg or placebo every 2 weeks. Data were analysed by trial and as a meta-analysis of individual patient-level data (pooled population) from REACH (alpha-fetoprotein ≥400 ng/ml) and REACH-2. Patients from REACH with Child-Pugh class B were analysed as a separate cohort. The ALBI grades and scores were calculated at baseline and before each treatment cycle. Results Baseline characteristics by ALBI grade were balanced between treatment arms among patients in the pooled population (ALBI-1, n = 231; ALBI-2, n = 296; ALBI-3, n = 7). Baseline ALBI grade was prognostic for overall survival (OS; ALBI grade 2 vs. 1; hazard ratio [HR]: 1.38 [1.13–1.69]), after adjusting for other significant prognostic factors. Mean ALBI scores remained stable in both treatment arms compared with baseline and were unaffected by baseline ALBI grade, macrovascular invasion, tumour response, geographical region, or prior locoregional therapy. Baseline ALBI grades 2 and 3 were associated with increased incidence of liver-specific adverse events and discontinuation rates in both treatments. Ramucirumab improved OS in patients with baseline ALBI grade 1 (HR 0.605 [0.445–0.824]) and ALBI grade 2 (HR 0.814 [0.630–1.051]). Conclusions Compared with placebo, ramucirumab did not negatively impact liver function and improved survival irrespective of baseline ALBI grade. Lay summary Hepatocellular carcinoma is the third leading cause of cancer-related death worldwide. Prognosis is affected by many clinical factors including liver function both before and during anticancer treatment. Here we have used a validated approach to assess liver function using 2 laboratory parameters, serum albumin and bilirubin (ALBI), both before and during treatment with ramucirumab in 2 phase III placebo-controlled studies. We confirm the practicality of using this more simplistic approach in assessing liver function prior to and during anticancer therapy, and demonstrate ramucirumab did not impair liver function when compared with placebo. In patients with HCC, the severity of coexisting liver dysfunction is usually categorised using the Child-Pugh system. We demonstrate that the simpler albumin–bilirubin (ALBI) nomogram can be used for pre-treatment prognostication and on-treatment assessment. Ramucirumab did not negatively impact on liver function compared to placebo in patients with advanced HCC and elevated AFP. Liver-specific adverse events were reported more frequently in patients with more severe liver disfunction at baseline. Ramucirumab provided a survival benefit irrespective of baseline liver function in patients with advanced HCC and elevated AFP.
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Key Words
- AE, adverse event
- AESI, adverse event of special interest
- AFP, alpha-fetoprotein
- ALBI
- ALBI, albumin–bilirubin
- ALT, alanine aminotransferase
- AST, aspartate aminotransferase
- BCLC, Barcelona Clinic Liver Cancer
- BOR, best overall response
- BSC, best supportive care
- CP, Child-Pugh
- CR, complete response
- ECOG PS, Eastern Cooperative Oncology Group performance status
- EoT, end of treatment
- GGT, gamma-glutamyltransferase
- HCC, hepatocellular carcinoma
- HR, hazard ratio
- IQR, inter-quartile range
- ITT, intent-to-treat
- Liver function
- MVI, macrovascular invasion
- OS, overall survival
- PD, progressive disease
- PR, partial response
- Prognosis
- Ram, ramucirumab
- SD, stable disease
- Safety
- Survival
- TACE, transarterial chemoembolisation
- Tumour response
- VEGF, vascular endothelial growth factor
- VEGFRs, vascular endothelial growth factor receptors
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Affiliation(s)
- Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University, Osaka-Sayama, Japan
| | - Peter R Galle
- Medizinische Klinik und Poliklinik, University Medical Center, Mainz, Germany
| | - Giovanni Brandi
- Department of Experimental, Diagnostic and Specialty Medicine, Saint Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Yoon-Koo Kang
- Department of Oncology, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
| | - Chia-Jui Yen
- Division of Hematology and Oncology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Richard S Finn
- Division of Hematology/Oncology, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Josep M Llovet
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Institut d´Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
| | - Eric Assenat
- Département d'oncologie médicale, CHU de Montpellier, Montpellier, France
| | - Philippe Merle
- Hepatology and Gastroenterology Unit, Hôpital de la Croix Rousse, Lyon, France
| | - Stephen L Chan
- State Key Laboratory of Translational Oncology, Chinese University of Hong Kong, Hong Kong, People's Republic of China.,Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong, People's Republic of China
| | - Daniel H Palmer
- Molecular and Clinical Cancer Medicine, Clatterbridge Cancer Centre, University of Liverpool, Bebington, Wirral, UK
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Tatsuya Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Ishikawa, Japan
| | - Arndt Vogel
- Klinik für Gastroenterologie, Hepatologie and Endokrinologie, Hannover Medical School, Hannover, Germany
| | - Yi-Hsiang Huang
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | - Ryan C Widau
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical Center, Boston, MA, USA
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