Hepatic Arterial Infusion Chemotherapy and Immunotherapy for Hepatocellular Carcinoma

Summary

Dear Sir/Madam, We would like to invite you to participate in this clinical research, which has been approved by the Medical Ethics Committee of Zhejiang Cancer Hospital. This informed consent form provides you with detailed information to help you decide whether or not to participate in this study. Please read it carefully, and ensure you fully understand it or get satisfactory answers to your questions before making your decision. If you have any questions, please feel free to consult the researchers, and we will provide you with comprehensive explanations. Hepatic artery infusion chemotherapy (HAIC) has recently become a popular local treatment method for liver cancer. A large Phase III clinical study from Sun Yat-sen University Cancer Center demonstrated that in a randomized comparison of HAIC versus transarterial chemoembolization (TACE) for unresectable large hepatocellular carcinoma (≥7 cm), the objective response rate (ORR) for HAIC was 46%, while TACE had an ORR of only 18%, with a statistically significant difference between the two. Additionally, HAIC showed advantages over TACE in terms of progression-free survival (PFS) and overall survival (OS), reducing the risk of disease progression by 43% and the risk of death by 42%. In subgroups based on age, sex, performance status, alpha-fetoprotein levels, tumor size, and number of tumors, HAIC consistently demonstrated superior PFS and OS. A study from Taiwan indicated that for patients with advanced liver cancer with portal vein tumor thrombus, the ORR for the HAIC group reached 22.86%, compared to 26.09% for those using immune checkpoint inhibitors alone, and an ORR of 50.00% for the group receiving HAIC combined with immune checkpoint inhibitors. FOLFOX (fluorouracil, leucovorin, and oxaliplatin) has shown positive results as a systemic treatment regimen for advanced liver cancer, with an ORR of 8.15%, a PFS of 2.93 months, and an OS of 6.47 months in comparative studies. When used as a treatment option in advanced liver cancer through hepatic artery infusion, its ORR increased to 31.5%, PFS to 7.8 months, and OS to 13.9 months. Common immune checkpoint inhibitors include PD-1 monoclonal antibodies and PD-L1 monoclonal antibodies. PD-1 antibodies prevent immune evasion by blocking PD-1 on immune cells, while PD-L1 antibodies block PD-L1 on tumor cells to inhibit their interaction, thus preventing immune evasion. Therefore, PD-1 monoclonal antibodies primarily target immune cells, while PD-L1 monoclonal antibodies primarily target tumor cells. This leads us to attempt hepatic artery infusion of PD-L1 monoclonal antibodies, utilizing a high-concentration saturation infusion method to maximally block PD-L1 on tumor cells and reduce tumor immune evasion. Concurrently, combining FOLFOX-HAIC localized chemotherapy leads to the release of tumor necrosis antigens, facilitating immune system activity. Thus, we aim to utilize hepatic artery infusion to deliver both PD-L1 monoclonal antibodies and chemotherapy into the liver, killing tumors with high concentrations of chemotherapy, which will lead to antigen release that aids subsequent immune drug effectiveness while reducing suppressive factors in the immune microenvironment, such as Tregs and M2 macrophages. This approach will help change the inhibitory status of the immune microenvironment and provide a foundation for subsequent immunotherapy. In BCLC staging, stage A patients and some stage B patients have resectable liver cancer. However, factors affecting tumor staging, such as maximum tumor diameter and tumor quantity, are also considered high-risk recurrence factors in clinical models. Therefore, later tumor staging itself is a high-risk factor for tumor recurrence. In 2009, Professor Mazzaferro and colleagues proposed the Up-to-Seven criteria (the sum of maximum tumor diameter and tumor number not exceeding 7). Patients who met this criteria and received liver transplantation had a five-year survival rate as high as 71%. Liver cancer patients exceeding the Up-to-Seven criteria are considered unsuitable candidates for liver transplantation, as exceeding this limit indicates a poor tumor biological behavior. Furthermore, the criteria align with the primary surgical treatment staging (CNLC Ia-IIa) recommended in the "Primary Liver Cancer Diagnosis and Treatment Guidelines (2024 Edition)" published by China's National Health Commission. Therefore, we plan to conduct a neoadjuvant study targeting resectable liver cancer exceeding the Up-to-Seven criteria, using hepatic artery chemotherapy combined with immune checkpoint inhibitor (PD-L1 monoclonal antibody) infusion as the treatment regimen.

Timeline

Start

2025-03-01

Primary completion

2026-06-30

Completion

2026-12-30

Publications

• Results Mazzaferro V, Llovet JM, Miceli R, Bhoori S, Schiavo M, Mariani L, Camerini T, Roayaie S, Schwartz ME, Grazi GL, Adam R, Neuhaus P, Salizzoni M, Bruix J, Forner A, De Carlis L, Cillo U, Burroughs AK, Troisi R, Rossi M, Gerunda GE, Lerut J, Belghiti J, Boin I, Gugenheim J, Rochling F, Van Hoek B, Majno P; Metroticket Investigator Study Group. Predicting survival after liver transplantation in patients with hepatocellular carcinoma beyond the Milan criteria: a retrospective, exploratory analysis. Lancet Oncol. 2009 Jan;10(1):35-43. doi: 10.1016/S1470-2045(08)70284-5. Epub 2008 Dec 4.
• Results Yang P, Qiu J, Li J, Wu D, Wan X, Lau WY, Yuan Y, Shen F. Nomograms for Pre- and Postoperative Prediction of Long-term Survival for Patients Who Underwent Hepatectomy for Multiple Hepatocellular Carcinomas. Ann Surg. 2016 Apr;263(4):778-86. doi: 10.1097/SLA.0000000000001339.
• Results Shen L, Qi H, Chen S, Cao F, Xie L, Wu Y, Ma W, Song Z, Yuan H, Zhang T, Li D, Wen X, Chen Q, Li W, Zhang X, Fan W. Cryoablation combined with transarterial infusion of pembrolizumab (CATAP) for liver metastases of melanoma: an ambispective, proof-of-concept cohort study. Cancer Immunol Immunother. 2020 Sep;69(9):1713-1724. doi: 10.1007/s00262-020-02566-z. Epub 2020 Apr 24.
• Results Lyu N, Wang X, Li JB, Lai JF, Chen QF, Li SL, Deng HJ, He M, Mu LW, Zhao M. Arterial Chemotherapy of Oxaliplatin Plus Fluorouracil Versus Sorafenib in Advanced Hepatocellular Carcinoma: A Biomolecular Exploratory, Randomized, Phase III Trial (FOHAIC-1). J Clin Oncol. 2022 Feb 10;40(5):468-480. doi: 10.1200/JCO.21.01963. Epub 2021 Dec 14.
• Results Wu JS, Hong TC, Wu HT, Lin YJ, Chang TT, Wang CT, Liu WC, Hsieh MT, Wu IC, Chen PJ, Chen CY, Lin SH, Chuang CH, Han MZ, Chen HP, Tsai HM, Kuo HY. Hepatic arterial infusion chemotherapy and immune checkpoint inhibitors, alone or in combination, in advanced hepatocellular carcinoma with macrovascular invasion: a single-centre experience in Taiwan. J Gastrointest Oncol. 2023 Apr 29;14(2):849-862. doi: 10.21037/jgo-22-858. Epub 2023 Apr 10.
• Results Li QJ, He MK, Chen HW, Fang WQ, Zhou YM, Xu L, Wei W, Zhang YJ, Guo Y, Guo RP, Chen MS, Shi M. Hepatic Arterial Infusion of Oxaliplatin, Fluorouracil, and Leucovorin Versus Transarterial Chemoembolization for Large Hepatocellular Carcinoma: A Randomized Phase III Trial. J Clin Oncol. 2022 Jan 10;40(2):150-160. doi: 10.1200/JCO.21.00608. Epub 2021 Oct 14.
• Results Xia Y, Tang W, Qian X, Li X, Cheng F, Wang K, Zhang F, Zhang C, Li D, Song J, Zhang H, Zhao J, Yao A, Wu X, Wu C, Ji G, Liu X, Zhu F, Qin L, Xiao X, Deng Z, Kong X, Li S, Yu Y, Xi W, Deng W, Qi C, Liu H, Pu L, Wang P, Wang X. Efficacy and safety of camrelizumab plus apatinib during the perioperative period in resectable hepatocellular carcinoma: a single-arm, open label, phase II clinical trial. J Immunother Cancer. 2022 Apr;10(4):e004656. doi: 10.1136/jitc-2022-004656.
• Results Marron TU, Fiel MI, Hamon P, Fiaschi N, Kim E, Ward SC, Zhao Z, Kim J, Kennedy P, Gunasekaran G, Tabrizian P, Doroshow D, Legg M, Hammad A, Magen A, Kamphorst AO, Shareef M, Gupta NT, Deering R, Wang W, Wang F, Thanigaimani P, Mani J, Troncoso L, Tabachnikova A, Chang C, Akturk G, Buckup M, Hamel S, Ioannou G, Hennequin C, Jamal H, Brown H, Bonaccorso A, Labow D, Sarpel U, Rosenbloom T, Sung MW, Kou B, Li S, Jankovic V, James N, Hamon SC, Cheung HK, Sims JS, Miller E, Bhardwaj N, Thurston G, Lowy I, Gnjatic S, Taouli B, Schwartz ME, Merad M. Neoadjuvant cemiplimab for resectable hepatocellular carcinoma: a single-arm, open-label, phase 2 trial. Lancet Gastroenterol Hepatol. 2022 Mar;7(3):219-229. doi: 10.1016/S2468-1253(21)00385-X. Epub 2022 Jan 20.
• Results Zhou WP, Lai EC, Li AJ, Fu SY, Zhou JP, Pan ZY, Lau WY, Wu MC. A prospective, randomized, controlled trial of preoperative transarterial chemoembolization for resectable large hepatocellular carcinoma. Ann Surg. 2009 Feb;249(2):195-202. doi: 10.1097/SLA.0b013e3181961c16.
• Results Gosavi R, Chia C, Michael M, Heriot AG, Warrier SK, Kong JC. Neoadjuvant chemotherapy in locally advanced colon cancer: a systematic review and meta-analysis. Int J Colorectal Dis. 2021 Oct;36(10):2063-2070. doi: 10.1007/s00384-021-03945-3. Epub 2021 May 4.
• Results De Lena M, Zucali R, Viganotti G, Valagussa P, Bonadonna G. Combined chemotherapy-radiotherapy approach in locally advanced (T3b-T4) breast cancer. Cancer Chemother Pharmacol. 1978;1(1):53-9. doi: 10.1007/BF00253147.
• Results Xia YX, Zhang F, Li XC, Kong LB, Zhang H, Li DH, Cheng F, Pu LY, Zhang CY, Qian XF, Wang P, Wang K, Wu ZS, Lyu L, Rao JH, Wu XF, Yao AH, Shao WY, Fan Y, You W, Dai XZ, Qin JJ, Li MY, Zhu Q, Wang XH. [Surgical treatment of primary liver cancer:a report of 10 966 cases]. Zhonghua Wai Ke Za Zhi. 2021 Jan 1;59(1):6-17. doi: 10.3760/cma.j.cn112139-20201110-00791. Chinese.
• Results Zeng H, Chen W, Zheng R, Zhang S, Ji JS, Zou X, Xia C, Sun K, Yang Z, Li H, Wang N, Han R, Liu S, Li H, Mu H, He Y, Xu Y, Fu Z, Zhou Y, Jiang J, Yang Y, Chen J, Wei K, Fan D, Wang J, Fu F, Zhao D, Song G, Chen J, Jiang C, Zhou X, Gu X, Jin F, Li Q, Li Y, Wu T, Yan C, Dong J, Hua Z, Baade P, Bray F, Jemal A, Yu XQ, He J. Changing cancer survival in China during 2003-15: a pooled analysis of 17 population-based cancer registries. Lancet Glob Health. 2018 May;6(5):e555-e567. doi: 10.1016/S2214-109X(18)30127-X.

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