Background
The evolving landscape of systemic therapy for HCC
Neoadjuvant immunotherapy
Methods/design
Eligibility criteria
Key inclusion criteria | Key exclusion criteria |
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1. Written informed consent for the trial 2. Aged ≥18 years 3. Confirmed diagnosis of HCC 4. Willing to provide tissue from an excisional biopsy of a tumour lesion 5. Have measurable disease by CT-scan or MRI defined by RECIST 1.1 criteria 6. Ineligible for liver transplantation 7. Medically fit to undergo surgery as determined by the treating medical and surgical oncology team. 8. ECOG-PS 0 or 1 9. Adequate hematologic function, defined as WBC ≥ 2000/μl, ANC ≥ 1500/μl, platelet count ≥50,000/μl and hemoglobin ≥8.5 g/dl without transfusion or Erythropoietin dependency. 10. Adequate renal function, defined as creatinine ≤1.5× ULN or measured or calculated creatinine clearance ≥40 ml/min for those with creatinine levels > 1.5× ULN 11. Adequate hepatic function, defined as total bilirubin ≤1.5× ULN, and ALT/AST levels ≤5× ULN, albumin ≥2.8 g/dL 12. Adequate coagulation function, defined as INR ≤ 1.5× ULN unless the patient is receiving anticoagulant therapy as long as PT or aPTT is within the therapeutic range 10. Overall Child-Pugh class A 11. Female patient of childbearing potential should have a negative serum pregnancy test within 24 h of her first dose of IMP 12. Women of childbearing potential must be willing to use a highly effective method of contraception 13. Sexually active males must agree to use an adequate method of contraception | 1. Extrahepatic metastasis 2. Prior systemic anticancer treatment for HCC, including an anti-PD-1, anti-PD-L1 or anti-CTLA-4 antibody 3. Prior orthotopic liver transplantation 4. Any major surgery within the 3 weeks prior to enrolment 5. Hepatic encephalopathy 6. Ascites that is refractory to diuretic therapy 7. Is currently receiving anti-cancer therapy (chemotherapy, radiation therapy, immunotherapy or biologic therapy) or has participated or is participating in a study with Nivolumab or Ipilimumab or used an investigational device within 4 weeks of the first dose of IMP 8. Diagnosis of immunodeficiency or is receiving systemic steroid therapy or any other form of immunosuppressive therapy 9. Known history of active Bacillus Tuberculosis 10. History of known hypersensitivity to any monoclonal antibody or any of their excipients 11. Known additional malignancy that is progressing or requires active treatment a 12. Active autoimmune disease that has required systemic treatment in the past 2 years b 13. Known history of, or any evidence of active, non-infectious pneumonitis 14. Active infection requiring systemic therapy c 15. History or current evidence of any condition, therapy, or laboratory abnormality that might confound the results of the trial 16. Known psychiatric or substance abuse disorders that would interfere with cooperation with the requirements of the trial 17. Pregnant or breastfeeding 18. Known history of Human Immunodeficiency Virus (HIV; HIV 1/2 antibodies) 19. Received a live vaccine within 30 days of first dose of IMP |
Planned sample size and study period
Study procedures
Outcome measures and endpoints
Adverse events management and dose modifications
irAE | Supportive Care Intervention |
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Grade 1 | Provide symptomatic treatment |
Grade 2 | Consider systemic corticosteroids in addition to appropriate symptomatic treatment. Steroid taper should be considered once symptoms improve to Grade 1 or less and tapered over at least 4 weeks. |
Grade 3 and Grade 4 | Systemic corticosteroids are indicated in addition to appropriate symptomatic treatment. May utilize 1 to 2 mg/kg prednisone or equivalent per day. Steroid taper should be considered once symptoms improve to Grade 1 or less and tapered over at least 4 weeks. Consider referral to organ-specific specialist (i.e. gastroenterologist, hepatologist, respiratory physician, endocrinologist) for any grade 3–4 irAEs, in order to evaluate substitution treatments and immune-modulating agents, such as anti-TNFα of other immune suppressants. |
Toxicity | Hold treatment for grade | Timing for restarting treatment |
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Diarrhoea/ Colitis | 2–3 | Toxicity resolves to Grade 0–1 |
4 | Permanently discontinue | |
AST, ALT, or Increased Bilirubin | 2 | Toxicity resolves to Grade 0–1 |
3–4 | Permanently discontinue (see exception below)a | |
Type 1 diabetes mellitus (if new onset) or Hyperglycaemia | T1DM or 3–4 | Hold the IMP for new onset Type 1 diabetes mellitus or Grade 3–4 hyperglycemia associated with evidence of beta cell failure |
Hypophysitis | 2–4 | Toxicity resolves to Grade 0–1. Therapy with IMP can be continued while endocrine replacement therapy is instituted |
Hyperthyroidism | 3 | Toxicity resolves to Grade 0–1 |
4 | Permanently discontinue | |
Hypothyroidism | N/A | Therapy with IMP can be continued while thyroid replacement therapy is instituted |
Infusion Reaction | 2b | Toxicity resolves to Grade 0–1 |
3–4 | Permanently discontinue | |
Pneumonitis | 2 | Toxicity resolves to Grade 0–1 |
3–4 | Permanently discontinue | |
Renal Failure or Nephritis | 2 | Toxicity resolves to Grade 0–1 |
3–4 | Permanently discontinue | |
All Other Drug-Related Toxicityc | 3 or Severe | Toxicity resolves to Grade 0–1 |
4 | Permanently discontinue |