Overview
This study evaluates the addition of nivolumab to TACE/TAE in the treatment of patients with intermediate stage hepatocellular carcinoma. All patients will receive TACE/TAE and half will receive nivolumab.
Description
A significant proportion of HCC patients present with, or progress to, intermediate stage disease and these patients are typically treated with transarterial chemo-embolisation (TACE) or transarterial embolisation (TAE).
However, since TACE/TAE is generally a palliative therapy, it provides a potential backbone for the addition of effective systemic therapies with the aim of improving survival outcomes. Since TACE may liberate an abundance of tumour antigens and 'danger' signals, it may lend itself to combination with immunotherapeutic strategies.
Nivolumab is a human monoclonal antibody. Nivolumab targets the programmed death-1 PD-1) cluster of differentiation 279 (CD279) cell surface membrane receptor. PD-1 is a negative regulatory molecule expressed by activated T and B lymphocytes.
Eligibility
Inclusion Criteria:
- Histological diagnosis of HCC and at least one uni-dimensional lesion measurable according to RECIST 1.1 criteria by CT-scan or MRI.
- Not a candidate for surgical resection or liver transplantation
- Aged 16 years and estimated life expectancy >3 months
- ECOG performance status 0-1
- Adequate haematological function:
- Hb 9g/L
- Absolute neutrophil count 1.0x109/L
- Platelet count 60x109/L
- Bilirubin 50 mol/L, AST,ALT and ALP 5 x ULN
- Adequate renal function; Creatinine 1.5ULN (Using Cockcroft-Gault Formula)
- INR 1.6
- Child-Pugh A (score 6) (Appendix D)
- HAP score A, B or C (Appendix E)
- No contra-indications to T-cell checkpoint inhibitor therapy (use of immunosuppressive drugs including steroids at dose equivalent to prednisolone >10mg/day unless used as replacement therapy; organ transplantation; subjects with an active, known or suspected autoimmune disease. Subjects with type I diabetes mellitus, hypothyroidism only requiring hormone replacement, skin disorders (such as vitiligo, psoriasis, or alopecia) not requiring systemic treatment, lichen planus or other conditions not expected to recur in the absence of an external trigger are permitted to enrol).
- Women of child-bearing potential should have a negative pregnancy test prior to study entry. Both men and women must be using an adequate contraception method, which must be continued for 5 months after completion of treatment for women and 7 months for men
- Written informed consent
Exclusion Criteria:
- Extrahepatic metastasis
- Prior embolisation, systemic or radiation therapy for HCC
- Any contraindications for hepatic embolisation procedures including portosystemic shunt, hepatofugal blood flow, known severe atheromatosis
- Investigational therapy or major surgery within 4 weeks of trial entry
- History of variceal bleeding within the past 4 weeks
- Child-Pugh cirrhosis B or C (score 7)
- HAP score D
- Hepatic encephalopathy
- Ascites refractory to diuretic therapy
- Documented occlusion of the hepatic artery or main portal vein5
- Hypersensitivity to intravenous contrast agents
- Active clinically serious infection > Grade 2 NCI-CTC
- Pregnant or lactating women
- Known history of HIV infection
- HBV chronic infection with HBV DNA > 500IU/mL or without antiviral therapy; HBV patients with cirrhosis should be treated.
- History of second malignancy except those treated with curative intent more than three years previously without relapse and non-melanotic skin cancer or cervical carcinoma in situ 18. Evidence of severe or uncontrolled systemic disease, or laboratory finding that in the view of the Investigator makes it undesirable for the patient to participate in the trial 19. Psychiatric or other disorder likely to impact on informed consent 20. Patient is unable and/or unwilling to comply with treatment and study instructions 20. Interstitial lung disease that is symptomatic or may interfere with the detection or management of suspected treatment-related pulmonary toxicity
- Evidence of uncontrolled, active infection, requiring parenteral anti-bacterial, anti-viral or antifungal therapy within 7 days prior to administration of study medication
- Positive test for latent TB or evidence of active TB
- Hypersensitivity to any of the active substances or excipients
- Patients who have received a live vaccine within 30 days prior to the first dose of trial treatment
- Subjects with a condition requiring systemic treatment with either corticosteroids (> 10 mg daily prednisone equivalent) or other immunosuppressive medications within 14 days of the first dose of study drug administration
- Any uncontrolled inflammatory GI disease including Crohn's Disease and ulcerative colitis
- Participants with an active, known or suspected autoimmune disease. Participants with type I diabetes mellitus, hypothyroidism only requiring hormone replacement, skin disorders (such as vitiligo, psoriasis, or alopecia) not requiring systemic treatment, or conditions not expected to recur in the absence of an external trigger are permitted to enrol