Mechanism of Sorafenib Resistance in Patients With Advanced Hepatocellular Carcinoma
Mechanism of Sorafenib Resistance in Patients With Advanced Hepatocellular Carcinoma
It has been shown previously that gene expression profiling signature (a set of dysregulated
 genes) can be used for molecular classification, diagnosis, and prognosis of several types of
 cancers. In This study the hypothesise that resistant tumor may be due to genetic mutations
 and/or other alternative pathways that could be the reason to overcome the Sorafenib and
 still proliferate.

 Primary objectives To evaluate the primary and secondary potential mechanisms by which HCC
 patients on Sorafenib treatment would be resistant to therapy and also identify the favorable
 genetic makeup of patients responding to treatment.

 Measures of primary outcome:

 -  cDNA microarray analysis on the MAP kinase pathway.

 -  mRNA quantification of genetic expression (RT-PCR) for identification of upregulated
 genes, and confirmed by corresponding proteomic testing (by Mass Spectroscopy) in the
 serum for potential serum markers. Secondary Objectives Progression free survival: Time
 to disease progression in patients in Saudi Arabia with HCC receiving Sorafenib:
 [defined as time, in weeks, from the baseline visit to progression of the disease or
 death from any cause] will be diagnosed using the RECIST criteria based on a trimestrial
 abdominal CT evaluation.

 -  Survival rates and Predictors of survival:

 -  Survival defined as the time from baseline visit to death from any cause [in
 weeks].

 -  Variables identified in multivariate regression analysis from overall treated
 patients independently associated with survival till study completion or death.
 Justification and Value to the Kingdom Sorafenib in the treatment of advanced HCC
 is a recent development. Since the only current effective treatment for advanced
 HCC is resection or transplantation and the list for these procedures are
 ever-growing due to the confounding effect of the lack of infrastructure in the
 Kingdom, selecting treatment for patients who are more likely to respond to
 Sorafenib treatment The Long-Term Comprehensive National Plan for Science,
 Technology and Innovation will help to reduce costs of managing HCC. Among Saudi
 Arabia population, there are a unique set of patients here (e.g. non-alcohol
 related HCC, genotype 4 HCV patients and genotype D HBV patients, high percentage
 of obese patients i.e. NASH) which is different from other parts of the world.
 There is increasing incidence of HCC in Saudi Arabia. Due to available expertise in
 management of HCC patients in the participating institutions in the study, this
 project will represent a bridge for the transfer of technology so that our research
 staff and doctors will have more expertise in carrying out these techniques
 independently. This study will also run in parallel to the on-going initiative to
 start a HCC biobanking establishment which will provide the samples needed to carry
 out our genetic studies in future. Finally, since the use of Sorafenib (at present,
 the only approved treatment for advanced HCC) in the treatment of advanced HCC is a
 new field, the findings of our study will have important implications in the
 management of HCC, both locally and internationally.

 HCC is the third most common cancer in Saudi Arabia. In 2001, HCC was the second most common
 cancer affecting Saudi males and the eighth most common cancer affecting females. Most of
 patients (90%) present at a more advanced stage when symptoms prevail.

 Given the high prevalence of HCC in the Kingdom, it is pertinent to study why some patients
 are resistant to Sorafenib compared to others. Elucidation of the differences in mechanisms
 among responders and non-responders to Sorafenib therapy will enable physicians to make
 better decisions in terms of treating Saudi HCC patients.
Introduction Hepatocellular carcinoma (HCC) is a major health problem, accounting for more
 than 626,000 new cases per year worldwide. It is the third highest cause of cancer-related
 death globally. In the west, the disease is diagnosed in 30 to 40% of all patients at early
 stages and is amenable to potentially curative treatments, such as surgical therapies
 (resection and liver transplantation) and locoregional procedures (radio-frequency ablation).
 There are no clear epidemiological studies in the Kingdom of Saudi Arabia that gives the real
 incidence of HCC in Saudi population, however the Saudi Cancer registration have labelled it
 as among the top five cancers in the country. Sorafenib has emerged as the treatment of
 choice in the treatment of advanced HCC and has demonstrated an anti-angiogenic and
 anti-proliferative effect. It is a kinase inhibitor that decreases tumor cell proliferation
 in Vitro. Sorafenib has been shown to inhibit multiple intracellular (CRAF, BRAF, and mutant
 BRAF) and cell surface kinases (KIT, FLT-3, RET, VEGFR-1, VEGFR-2, VEGFR-3 and PDGFR-B).
 Several of these kinases are thought to be involved in tumor cell signaling, angiogenesis and
 apoptosis. In a phase 3 international, multi-center, randomised, doubleblind,
 placebo-controlled trial in patients with unresectable hepatocellualr carcinoma Sorafenib
 showed a statistically significant advantage over placebo for overall survival (HR: 0.69,
 p=0.00058). Final analysis of time to tumor progression also was significantly longer in the
 Protocol number: 1.0 dated 01Aug2013 Short title: HCC - Sorafenib study Confidential Page 11
 The Long-Term Comprehensive National Plan for Science, Technology and Innovation Sorafenib
 arm. This benefit was calculated in months because of the quick emergence of resistance in
 many patients. Therefore, individualizing the treatment to patients with most expected
 response and avoiding it in patients with resistant cancers has stimulated this research to
 evaluate why some patients develop resistance to this therapy.

 Literature review Epidemiology Hepatocellular carcinoma (HCC) is the sixth most common cause
 of cancer worldwide with an annual incidence of over 711,000 new cases, and the third most
 common cause of cancer death with an annual mortality of 679,000 patients. Most commonly HCC
 develops in cirrhosis, irrespective of the etiology. In the western world, chronic alcohol
 abuse and nonalcoholic stratohepatitis are about the as important etiologic factors for
 cirrhosis as chronic hepatitis c. In chronic hepatitis C it is estimated that about 20% of
 patients will eventually develop cirrhosis after 20-30 years of infection. Once cirrhosis is
 established, the annual risk of developing HCC is estimated to be between 3 and 4 %, largely
 irrespective of the etiology of cirrhosis. Diagnosis of HCC HCC is mostly asymptomatic in
 early stage disease. Without proper surveillance programs of cirrhotic patients, diagnosis is
 only established in advanced stage disease. The efficacy of surveillance by Ultrasound (and
 to a lesser extent by alpha-fetoprotein measurement) has been established in prospective
 trials in the west as well in the east. surveillance by experienced sonographers makes
 curative treatment possible treatment possible in up to 75% of patients,while there is no
 curative treatment without proper surveillance. Surveillance is recommended for the following
 groups of patients: Hepatitis B carriers Asian males > 40 years, Asian females >50 years, All
 cirrhotic hepatitis B carriers, Family history of HCC, Africans over age 20. For
 non-cirrhotic hepatitis B carriers not listed above the risk of HCC varies depending on the
 severity of the underlying liver disease, the Long-Term Comprehensive National Plan for
 Science, Technology and Innovation inflammatory activity. Patients with high HBV DNA
 concentrations and those with ongoing hepatic inflammatory activity remain at risk for HCC.
 Non-hepatitis B cirrhosis Hepatitis C, Alcoholic cirrhosis, Genetic hemochromatosis, Primary
 biliary cirrhosis. Although the following groups have an increased risk of HCC no
 recommendations for or against surveillance can be made because a lack of data precludes an
 assessment of whether surveillance would be beneficial - Alpha1-antitrypsin deficiency
 ,Non-alcoholic steatohepatitis, Autoimmune hepatitis. Once a lesion is detected by
 ultrasound, the diagnosis can be established radiologically in lesions with typical
 appearance above 1 cm in diameter. Biopsy is mandated only in cases with atypical
 presentation on imaging. Staging of HCC Staging of HCC can be done using several systems.
 currently, the most widely used staging system is the Barcelona Clinic Liver Cancer (BCLC)
 staging system , which takes the underlying liver disease, tumor characteristics, as well as
 the general performance status into account . This staging system is popular as it is
 directly linked to treatment, making treatment decisions easy. Advanced stage HCC: the
 current role of medical therapies In western countries, about 30 % of patients are identified
 with an HCC in BCLC stage 0 or A, either through surveillance or by chance. For those
 patients curative options can be applied, which currently involve only surgical or
 interventional treatments. However , curatively treated patients , except for those who
 underwent transplantation, will have a tumor recurrence in 70 to 80 % of cases within 5 years
 of therapy and will eventually progress to BCLC B or BCLC C stage disease. Another 20 % of
 patients are diagnosed at very advanced stages BCLC D, being either symptomatic from the
 decompensated cirrhosis (Child-Pugh C) or having an advanced tumor. Those patients have a
 very short survival, which cannot be influenced by any therapeutic intervention and are only
 eligible to receive best supportive care. Currently, the domain of medical therapies for HCC
 is in the setting of advanced stage BCLC C. Conventional chemotherapy of any kind has never
 shown any meaningful therapeutic benefit, particularly in overall survival in randomized
 controlled trials in adult patients and cannot be recommended for the treatment of HCC today.
 Conventional cisplatin-based chemotherapy, Technology and Innovation without doxorubicine
 only has a place in the treatment of childhood hepatoblastoma, which is a distinctly
 different disease entity. In hepatoblastoma cisplatin-based chemotherapy does improve
 survival and can even provide a cure in over 80% of patients when combined with resection.
 Medical treatment of HCC changed dramatically in 2007 , when the first data from the
 successful use of targeted agents in advanced stage HCC, in particular tyrosine kinase
 inhibitors, were presented. Up-regulated signaling through the mitogen-activated protein
 kinase (MAPK) intracellular signal transduction pathway plays a crucial role in the
 development of hepatocellular carcinoma , as does tumor angiogenesis .The MAPK pathway
 comprises Raf ,MAPK kinase (MEK ) and extracellular signal-regulated Kinase (ERK), and is a
 mediator of tumor proliferation, differentiation and survival. The identification of pivotal
 pathways, such as the MAPK cascade, led to the development of targeted treatments, such as
 Sorafenib. Sorafenib is an orally active multikinase inhibitor that inhibits cell surface
 tyrosine kinases, as well as downstream intracellular Raf kinases in the MAPK cascade.
 Sorafenib is widely available for the use in the treatment of advanced renal cell carcinoma
 and has been reviewed in this indication previously. Recently, Sorafenib was also approved in
 the US and the EU for use in the treatment of hepatocellular carcinoma, the first systemic
 drug to be approved in this indication. Indeed, current US treatment guidelines recommend
 Sorafenib as the first-lone treatment option in patients with unresectable HCC who are
 Child-Pugh class A. Receptor tyrosine Kinases inhibited by Sorafenib include vascular
 endothelial growth factor receptor (VEGFR)-1, VEGFR-2, VEGFR-3, Platelet-derived growth
 factor receptor (PDGFR)-B, cKIT, FMS-like tyrosine kinase 3 (FLT-3) and RET. Intracellular
 Raf serine/threonine kinase isoforms inhibited by Sorafenib include Raf-1(or C-Raf), wild
 -type B-Raf and Mutant B-Raf. These kinases are involved in tumor cell proliferation and
 tumor angiogenesis. In vitro, dose-dependent inhibition of cell proliferation was seen with
 Sorafenib in the human hepatocellular carcinoma cell lines PLC/PRF/5 and HepG2. Moreover,
 dose dependent induction of apoptosis was seen after Sorafenib exposure, as assessed by TUNEL
 (terminal deoxynucleotide transferase d-uridine triphosphate nick end labeling) staining.
 Inhibition by Sorafenib of the Raf/MEK/ERK signaling pathway in PCL/PRF/5 and HepG2 cells was
 shown by, among other things, the inhibition of MEK and ERK phosphorylation. Sorafenib
 demonstrated Protocol number: 1.0 dated 01Aug2013 Short title: HCC - Sorafenib study
 Confidential Page 14 The Long-Term Comprehensive National Plan for Science, Technology and
 Innovation dose-dependent antitumor activity in murine xenograft model of PCL/PRF/5 human
 hepatocellular carcinoma. Significant tumor growth inhibition of 49% and 78% was seen in mice
 receiving oral Sorafenib 10 or 30 mg/kg/day for 16 or 21 days ( both P 16 weeks and 48
 (35.0%) had progressive disease (the remaining 32 patients [23.4%] were not available for
 independent review). With Sorafenib, the median time to progression was 4.2 months
 (investigator assessment) or 5.5 months (independent assessment), and the median overall
 survival duration was 9.2 months. Phase III trial The clinical efficacy of oral Sorafenib was
 examined in patients with advanced HCC in a randomized, double-blind, placebo-controlled,
 multi center, phase III trial (the SHARP study) (22). Inclusion criteria were histologically
 proven, advanced hepatocellular carcinoma, with at least one measurable untreated lesion, an
 ECOG performance status of 0-2, Child-Pugh class A and no prior systemic treatment . 902
 patients were screened and 602 were randomized to receive oral Sorafenib 400 mg twice daily
 (n=299) or placebo (n=303). The median duration of treatment was 23 weeks in Sorafenib
 recipients and 19 weeks in placebo recipients. Prior to randomization, patients were
 stratified according to macroscopic vascular invasion and/or extrahepatic spread, ECOG
 performance status and Geographical region. In terms of baseline characteristics, mean
 patient age was 65.5 years; 87% of patients were male; 87.5% of patients were from Europe;
 96.5% of patients were Child-Pugh class A; 54%, 38.5% and 7.5% of patients had an ECOG
 performance status of 0, 1, 2 at baseline; 17.5% and 82.5% of patients had Barcelona Clinic
 Liver Cancer Group stage B and C cancer; and 70% of patients had vascular invasion and/or
 extrahepatic spread . The primary endpoints were overall survival and time to symptomatic
 progression (defined as the time from randomization to a 4-point decline from baseline in
 patient response to the Functional Assessment Of Cancer Treatment Hepatobiliary Symptom index
 [FHSI-8] confirmed at next visit , deterioration to ECOG performance status 4, or death). The
 time to progression (assessed by independent central review) was a pre-specified secondary
 endpoint. Tumor response rates were assessed using Response Evaluation Criteria in Solid
 Tumors (RECIST). Analyses were conducted in the intent-to-treat (ITT) population (22).
 Sorafenib significantly improved survival in patients with advanced hepatocellular carcinoma
 in the SHARP trial (22). The median duration of survival was 10.7 months with Sorafenib and
 7.9 months with placebo, yielding a hazard ratio (HR) of 0.69 (95% CI 0.55, 0.88; P =
 0.00058). Following the second planned interim analysis, the SHARP study was terminated early
 on the basis of this survival result. At the time of study termination, there was no
 significant difference between Sorafenib and placebo recipients in the time to symptomatic
 progression (assessed using FHSI-8 criteria). The median time to progression (assessed by
 independent central review) was significantly longer in patients receiving Sorafenib than
 those receiving placebo (5.5 vs. 2.8 months), with an HR of 0.58(95% CI 0.44, 0.74; P Overall
 study design Screening and Pre-Treatment Period Investigator/ Co-Investigator/Study
 Coordinator • Medical history • Biopsy and review of pathology • Physical examination and
 vital signs • Review of previous or concurrent medications and procedures • Child-Pugh
 assessment • ECOG assessment • Lesion(s) measurement • Determination of study eligibility •
 Written, signed and date informed consent Laboratory investigations • Hematology: CBC,
 Differential • Serology: HBV, HCV, and HIV • The levels of the Bimarkers: c-KIT, Soluble
 VEGFR-2,-3. • Coagulation: platelets, PT, PTT, INR • Liver function tests • Serum pregnancy
 test (as appropriate) Radiological investigations • CT scan (or MRI) of the chest • CT scan
 (or MRI) of the abdomen • PET Scan Patient • Review of patient information leaflet Treatment
 period Baseline Visit - Day 1 Investigator/ Co-Investigator/Study Coordinator • Review of
 concomitant medications and therapies • Review of ECOG • Prescription of Sorafenib Patient •
 Start of the Sorafenib 6-8 weeks cycle Sorafenib Cycle Week 0-6/8 Laboratory investigations
 to be done on a weekly basis • Hematology: CBC, Differential • Serology: HBV, HCV, and HIV •
 Coagulation: platelets, PT, PTT, INR results of laboratory investigations on a weekly basis •
 See patients every other week Patient • Takes the appropriate dose of Sorafenib • Goes for
 blood test every week • Consult with the investigator/co-investigator every other week Visit
 after first Sorafenib cycle (Week 5 + 1 week) Investigator/ Co-Investigator/Study Coordinator
 • Physical examination • Review of concomitant medications and therapies • Child-Pugh
 re-assessment • ECOG re-assessment • Lesion(s) measurement • Recording of Adverse events
 Laboratory investigations • Hematology: CBC, Differential • Coagulation: platelets, PT, PTT,
 INR • Liver function tests Radiological investigations • CT scan (or MRI) of the abdomen
 Follow-up Visits (Every 3 months)* Investigator/ Co-Investigator/Study Coordinator • Physical
 examination • Review of concomitant medications and therapies • Child-Pugh re-assessment •
 ECOG re-assessment • Lesion(s) measurement • Recording of Adverse events Laboratory
 investigations • Hematology: CBC, Differential • Coagulation: platelets, PT, PTT, INR • The
 Bio-markers: c-KIT, VEGFR -2,-3 at week 12. • Liver function tests Radiological
 investigations • CT scan (or MRI) of the abdomen *The patient is going to be followed up in
 the basis of either stable disease or partial response or progression this based on
 radiological profession (which is assessed by RECIST). For those with progression other
 Biopsy will be taken and the tissue to be evaluated further.

 Study procedures All laboratory tests will be conducted as normal with additional specific
 tests to be performed in Liver Disease Research Center (LDRC), or the Proteomics Lab,
 KSU-Riyadh. Blood will be collected in three 7ml tubes with each biopsy. cDNA microarray
 analysis will be done on the pathways acted on by Sorafenib, namely the MAP kinase pathway.
 The analysis will be done at LDRC, KSU-Riyadh. • Tissue samples will be obtained in all
 patients from the tumor under imaging guidance • Tumor tissue biopsies will be performed at
 baseline and at end-of-study/when study endpoint is met o A minimum of 3 cm of tumor tissue
 will be obtained (2-3 needle passes). o Transportation of samples to the LDRC will be done on
 dry ice. o Tissue obtained will be snap frozen at -800C until processing. o Tissue will be
 tested for genes involved in the RAF pathway. o Genetic expression from the fresh tumor
 tissue will be quantified using RT-PCR for mRNA quantification. Once upregulated genes are
 identified, their corresponding proteomic expression will be tested in the serum for
 potential serum markers. Proteomic testing will be performed using Mass Spectroscopy.
 Additional specific blood tests will be performed in LDRC. Blood will be collected in two 7
 ml EDTA tubes (purple top) and one plain tube (red top). Blood samples will be collected at
 the same time with the liver biopsy. Blood once collected will be transported immediately to
 LDRC on dry ice and stored at -80oC. Samples will be thawed and data analysed when the
 individual patient has met study end-point or at study completion, as relevant. Liver biopsy
 samples will also be transported on dry ice to LDRC and snap-frozen at -80oC for subsequent
 analysis. Blood and tissue will be collected and transported by pre-arrangement with LDRC
 staff, and will be coordinated by the SOLID registrar (Nouf Alanezi) and/or the study CRC in
 KAMC-Riyadh. All patient-related data, including demographic, clinical, laboratory, and
 radiological data will be collected in the comprehensive HCC eCRF of the SOLID registry where
 appropriate. As a feature of the registry, all patient-related data is encoded in order to
 remove any patient identifiers. All blood samples stored for end-of-study investigations will
 be barcoded and the stickers tagged to the SOLID registry identifiers for easy retrieval.

 Study subjects The study is expected to run for about 3 years and patients will be followed
 for a period of 24 months. All consecutive patients presenting with HCC satisfying study
 inclusion and exclusion criteria will be approached for participation. At an average, about
 200 patients with HCC are evaluated annually in the multi study centres. We anticipate that
 60 patients would be eligible for the study of whom 40 would be recruited for the study. A
 total of 40 patients will be recruited from 2 - 3 centers in KSA (KSU, LDRC; KAMC-Riyadh). Of
 these 15 patients will be recruited from King Abdulaziz Medical City, Riyadh. Recruitment is
 planned to be completed in the first year of the study.

 Duration of treatment and removal of subjects Patients will be followed for a period of 24
 months. Patients removed from study for unacceptable adverse events will be followed until
 resolution or stabilization of the adverse event. Patients are to continue therapy with
 Sorafenib until • Disease progression • Until a criterion is met for stopping therapy like o
 Concurrent illness that prevents further administration of treatment o Unacceptable adverse
 events(s) o Patient decides to withdraw from the study o General or specific changes in the
 patient's condition render the patient unacceptable for further treatment in the judgment of
 the investigator. In the event of radiologic progression, patients may continue to receive
 the study drug. Decisions about continuing study medication will be made at the discretion of
 the investigator, based on the investigator's judgment about the patient's clinical status.
 In general, it is suggested that patients remain on Sorafenib if, in the opinion of the
 investigator, the patient may be benefiting from continuing on study drug Removal of subjects
 and the reason of the removal will be documented.

 Treatment description No investigational or commercial agents or therapies other than
 Sorafenib may be administered with the intent to treat the patient's malignancy. Sorafenib
 will be given at the dose of 2 tablets of 200mg (400 mg) to be taken twice a day in the
 morning and in the evening without food (at least 1 hour before or 2 hours after a meal). If
 a dose reduction is necessary, the Sorafenib dose may be reduced to 200 mg twice a day. If
 additional dose reduction is required, the dose may be reduced to a single 400 mg dose every
 other day. Reported adverse events, potential risks, and appropriate dose modifications for
 are described below. Informed Consent: If a patient is found to meet the eligibility criteria
 and expresses an interest in participation, Other treatment options will also be discussed
 with the patient prior to completing informed consent. No study related procedures will be
 conducted prior to the patient signing the informed consent. The subject will be provided
 with a copy of the Patient Information Sheet and will be given the opportunity to ask any
 question or seek clarification.
Inclusion Criteria:

 Male or female patient over 18 years of age

 -  Patient who have a life expectancy of at least 12 weeks

 -  Biopsy proven diagnosis of hepatocellular carcinoma

 -  Liver lesions are visible and measurable of at least 3 cm in size

 -  Advanced HCC, defined by the presence of one of the followings:

 -  Vascular invasion

 -  HCC with cancer-related symptoms with ECOG Score of 0, 1 or 2

 -  Progression after resection or local ablation and not for further curative
 therapies

 -  Cirrhotic status of Child-Pugh class A and B (score ≤ 8)

 -  The following laboratory parameters:

 -  Platelet count > 50 X 109 /L

 -  Hemoglobin > 85 g/L

 -  Total bilirubin < 51.3 umol/L

 -  ALT and AST < 5X upper limit of normal

 -  Amylase and lipase < 1.5 X the upper limit of normal

 -  Serum creatinine < 1.5 X the upper limit of normal

 -  Prothrombin time (PT) international normalized ratio (INR) < 2.3 or PT < 6
 seconds above control. Patients who are being therapeutically anticoagulated with
 an agent such as Coumadin or heparin will be allowed to participate provided that
 no prior evidence of underlying abnormality in these parameters exists.

 -  Able to give written informed consent prior to any study specific screening procedures
 with the understanding that the patient has the right to withdraw from the study at
 any time, without prejudice.

 -  Any institution/centre specific criteria that must be adhered to for the patient to be
 eligible.

 Exclusion Criteria:

 Previous or concurrent cancer that is distinct in primary site or histology from HCC.

 Except:

 -  Cervical carcinoma in situ

 -  Prostate cancer with good prognosis

 -  Treated basal cell carcinoma

 -  Superficial bladder tumors (Ta, Tis & T1)

 -  Any cancer curatively treated 3 years prior to entry is permitted.

 -  A Child-Pugh rating of C at entry

 -  An ECOG performance score of 3 or 4 at entry

 -  Extensive extra-hepatic disease

 -  Tumor volume > 50% of liver volume

 -  Contraindication to angiography or selective visceral catheterization

 -  Any bleeding diathesis or coagulopathy that is not correctable by usual therapy
 or hemostatic agent

 -  Severe peripheral vascular disease precluding catheterization

 -  History of severe allergy or intolerance to contrast agents, narcotics, sedatives
 or atropine that cannot be managed medically

 -  Platelet count < 30,000 or < 50% prothrombin activity

 -  Renal failure requiring hemo-or peritoneal dialysis

 -  Pulmonary insufficiency (clinically evident history of chronic obstructive
 pulmonary disease)

 -  History of cardiac disease:

 -  Congestive heart failure > New York Heart Association (NYHA) class2

 -  Active coronary artery disease

 -  Uncontrolled hypertension

 -  Active clinically serious infection(s)

 -  Known history of human immunodeficiency virus (HIV) infection

 -  Patient with clinically significant gastrointestinal bleeding within 30 days
 prior to study entry

 -  History of organ allograft/transplantation

 -  Substance abuse, medical, psychological or social conditions that may interfere
 with the patient's participation in the study or evaluation of the study results

 -  Known or suspected allergy to the investigational agent or any agent given in
 association with this trial

 -  Patients unable to swallow oral medications

 -  Any condition that is unstable or which could jeopardize the safety of the
 patient and his/her compliance in the study

 -  Pregnant or breast-feeding patients

 -  Women of childbearing potential must have a negative pregnancy test performed
 within seven days prior to the start of study drug.

 -  Both men and women enrolled in this trial must use adequate barrier birth control
 measures during the course of the trial.

 Excluded therapies and medications - previous and concomitant:

 -  Prior use of any systemic anti-cancer chemotherapy for HCC

 -  Prior use of systemic investigational agents for HCC

 -  Prior use of Raf-kinase inhibitors (RKI), VEGF inhibitors, EMK inhibitors or Farnesyl
 transferase inhibitors

 -  Major surgery within 4 weeks of start of the study drug

 -  Use of biologic response modifiers, such as granulocytes colony-stimulating factor
 (G-CSF) within 3 weeks prior to study entry (G-CSF and other hematopoietic growth
 factors may be used in the management of acute toxicity such as febrile neutropenia
 when clinically indicated or at the discretion of the investigator; however they may
 not be substituted for a required dose reduction)

 -  Patients taking chronic erythropoietin are permitted provided no dose adjustment is
 undertaken within 1 month prior to the study or during the study.

 -  Autologous bone marrow transplant or stem cell rescues within four months of start of
 study drug

 -  Concomitant treatment with rifampin and St John's wort