TACE Combined With Anti-PD-1 Antibody in Patients With Advanced Hepatocellular Carcinoma
TACE Combined With Anti-PD-1 Antibody in Patients With Advanced Hepatocellular Carcinoma
The objective of this study is to evaluate the efficacy and safety of transcatheter arterial
 chemoembolization combined with anti-pd-1 antibody in patients with advanced hepatocellular
 carcinoma as first line therapy.
The transarterial chemoembolization (TACE) is commonly used for the treatment of advanced
 hepatocellular carcinoma. Early randomized trials suggested that TACE can be accepted as the
 standard treatment for advanced stage disease. However, outcome of patients treated with TACE
 in real-life cohorts is still very poor.

 Recent studies have also supported a safe combination of immune checkpoint inhibition with
 TACE. Therefore, the objective of this study is to evaluate the efficacy and safety of TACE
 combined with anti-pd-1 antibody in patients in advanced hepatocellular carcinoma.
Inclusion Criteria:

 -  Written informed consent obtained.

 -  Age ≥ 18 years at time of study entry.

 -  Multinodular or large, solitary hepatocellular carcinoma, not eligible for resection
 or local ablation, Tumor burden below 50% of liver volume.

 -  Histologically confirmed diagnosis of hepatocellular carcinoma.

 -  At least one measurable site of disease as defined by modified RECIST (mRECIST)
 criteria with spiral CT scan or MRI.

 -  Child-Pugh scores 5-7, performance status (PS) ≤ 2 (ECOG scale).

 -  Subjects with chronic HBV infection must have HBV DNA viral load < 100 IU/mL at
 screening. In addition, they must be on antiviral therapy per regional standard of
 care guidelines prior to initiation of study therapy.

 -  Life expectancy of at least 12 weeks.

 -  Adequate blood count, liver-enzymes, and renal function: absolute neutrophil count ≥
 1,500/L, platelets ≥60 x103/L; Total bilirubin ≤ 3x upper normal limit; Aspartate
 Aminotransferase (SGOT), Alanine aminotransferase (SGPT) ≤ 5 x upper normal limit
 (ULN); International normalized ratio (INR) ≤1.25; Albumin ≥ 31 g/dL; Serum Creatinine
 ≤ 1.5 x institutional ULN or creatinine clearance (CrCl) ≥ 30 mL/min (if using the
 Cockcroft-Gault formula )

 -  Female patients with reproductive potential must have a negative urine or serum
 pregnancy test within 7 days prior to start of trial.

 -  Subject is willing and able to comply with the protocol for the duration of the study
 including undergoing treatment, adherence to contraceptive measures, scheduled visits
 and examinations including follow up.

 Exclusion Criteria:

 -  Diffuse hepatocellular carcinoma or presence of vascular invasion or extrahepatic
 spread with the following exceptions: Invasion of a segmental portal vein or hepatic
 veins; or limited extrahepatic metastases with one organ system manifestations.

 -  Patients on a liver transplantation list or with advanced liver disease.

 -  Total thrombosis or total invasion of the main branch of the portal vein.

 -  History of cardiac disease, including clinically significant gastrointestinal bleeding
 within 4 weeks prior to start of study treatment

 -  Thrombotic or embolic events such as cerebrovascular accident (including transient
 ischemic attacks), deep vein thrombosis or pulmonary embolism within the 6 months
 Prior to the first dose of study drug with the exception of thrombosis of a segmental
 portal vein.

 -  Prior systemic anti-cancer therapy OR endocrine- OR immunotherapy

 -  Prior treatment with TACE

 -  Radiofrequency ablation and resection administered less then 4 weeks prior to study
 treatment start.

 -  Radiotherapy administered less then 4 weeks prior to study treatment start.

 -  Major surgery within 4 weeks of starting the study treatment OR subjects who have not
 recovered from effects of major surgery.

 -  Patients with second primary cancer, except adequately treated basal skin cancer or
 carcinoma in-situ of the cervix.

 -  Immunocompromised patients, e.g. patients who are known to be serologically positive
 for human immunodeficiency virus (HIV).

 -  Participation in another clinical study with an investigational product during the
 last 30 days before inclusion or 7 half-lifes of previously used trial medication,
 whichever is longer.

 -  Previous treatment in the present study (does not include screening failure).

 -  Any condition or comorbidity that, in the opinion of the investigator, would interfere
 with evaluation of study Treatment or interpretation of patient safety or study
 results, including but not limited to:

 1. history of interstitial lung disease

 2. Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) coinfection (i.e double
 infection)

 3. known acute or chronic pancreatitis

 4. active tuberculosis

 5. any other active infection (viral, fungal or bacterial) requiring systemic
 therapy

 6. history of allogeneic tissue/solid organ transplant

 7. diagnosis of immunodeficiency or patient is receiving chronic systemic steroid
 therapy or any other form of immunosuppressive therapy within 7 days prior to the
 first dose of nivolumab-monotherapy treatment.

 8. Has an active autoimmune disease requiring systemic treatment within the past 3
 months or a documented history of clinically severe autoimmune disease, or a
 syndrome that requires systemic steroids or immunosuppressive agents. Exceptions:
 Subjects with vitiligo, hypothyroidism, diabetes mellitus type I or resolved
 childhood asthma/atopy are an exception to this rule. Subjects that require
 intermittent use of bronchodilators or local steroid injections would not be
 excluded from the study. Subjects with Hashimoto thyroiditis, hypothyroidism
 stable on hormone replacement or psoriasis not requiring treatment are not
 excluded from the study.

 9. Live vaccine within 30 days prior to the first dose of nivolumab-monotherapy
 treatment or during study treatment.

 10. History or clinical evidence of Central Nervous System (CNS) metastases
 Exceptions are: Subjects who have completed local therapy and who meet both of
 the following criteria: I. are asymptomatic and II. have no requirement for
 steroids 6 weeks prior to start of nivolumab-monotherapy treatment. Screening
 with CNS imaging (CT or MRI) is required only if clinically indicated or if the
 subject has a history of CNS

 -  Medication that is known to interfere with any of the agents applied in the trial.

 -  Any other efficacious cancer treatment except protocol specified treatment at study
 start.

 -  Patient has received any other investigational product within 28 days of study entry.

 -  Prior therapy with an anti-Programmed cell death protein 1 (anti-PD-1), anti-PD-L1,
 anti-Programmed cell death-ligand 2 (anti-PD-L2), anti-CD137 (4-1BB ligand, a member
 of the Tumor Necrosis Factor Receptor (TNFR) family), or anti-Cytotoxic
 T-lymphocyte-associated antigen-4 (anti-CTLA-4) antibody (including ipilimumab or any
 other antibody or drug specifically targeting T-cell co-stimulation or checkpoint
 pathways).

 -  Female subjects who are pregnant, breast-feeding or male/female patients of
 reproductive potential who are not employing an effective method of birth control
 (failure rate of less than 1% per year). [Acceptable methods of contraception are:
 implants, injectable contraceptives, combined oral contraceptives, intrauterine
 pessars (only hormonal devices), sexual abstinence or vasectomy of the partner]. Women
 of childbearing potential must have a negative pregnancy test (serum β-HCG) at
 screening.

 -  Patient with any significant history of non-compliance to medical regimens or with
 inability to grant reliable informed consent.