1. Future developments

2. AASLD-JNCI guidelines in HCC
Trial design
Llovet JM, et al. J Natl Cancer Inst. 2008;100: 5 5 2 7

3. HCC trial design strategy recommended by AASLD expert panel
Early clinical research phase
Advanced clinical research phase
Phase 1/2 study
Randomized phase 2
Combined phase 2–3
Phase 3 study
Combined phase 1/2 studies in cirrhotic patients will capture liver-specific toxic effects of new drugs
Randomized phase 2 trials are pivotal in HCC research because they enable reliable comparison with standard of care
Phase 3 studies remain the main source of evidence in HCC research
Phase 2/3 studies may be appropriate in very specific circumstances, where the drug proposed would require fast-track assessment
Llovet JM, et al. J Natl Cancer Inst. 2008;100: 3 3 3

4. Endpoints in clinical trials recommended by AASLD expert panel
Recommended primary and secondary endpoints
Survival
Time from randomization to death. Patients alive at the end of follow-up are censored
Primary endpoint in phase 3 studies assessing primary treatments
Primary/secondary endpoint in phase 2/3 studies assessing adjuvant or neoadjuvant treatments
Secondary endpoint in phase 2 studies assessing primary treatments
Time to recurrence (TTR)*
Time from randomization to recurrence. Evidence of recurrence should follow the RECIST amendments. Once evidence of HCC recurrence is confirmed, TTR will be defined as the time that recurrence was first suspected
Time to progression*
Time from randomization to radiological progression. Definition of progression is based on the RECIST amendments. Deaths during follow-up without evidence of radiological progression are censored
Primary endpoint in phase 2 studies assessing primary treatments
Secondary endpoint in phase 3 studies assessing primary treatments
Time to local recurrence*
Time from randomization to local radiological progression. Definition of progression is based on the RECIST amendments. Deaths during follow-up without evidence of radiological progression are censored
Secondary endpoint in studies assessing locoregional therapies
*Time to progression and time to local recurrence can vary considerably if evaluation interval varies among studies or between study arms of an individual study.
RECIST = Response Evaluation Criteria in Solid Tumors.
Llovet JM, et al. J Natl Cancer Inst. 2008;100:

5. Endpoints in clinical trials recommended by AASLD expert panel
Recommended primary and secondary endpoints
Tertiary endpoints†
Cancer-specific death
Time from randomization to HCC-related death. Patients alive at the end of follow-up are censored
Competing risk analysis is recommended to assess this endpoint
Time to symptomatic progression
Time from randomization to deterioration of symptoms as assessed by a standardized questionnaire
No reliable questionnaires have been thoroughly validated in HCC research
Disease-free survival
Composite endpoint. Time from randomization to either recurrence or death. Patients alive and free of recurrence at the end of follow-up are censored
Vulnerable endpoint in HCC research
Progression-free survival
Composite endpoint. Time from randomization to either radiological progression or death. Patients alive and free of progression at the end of follow-up are censored
Response rate
Definition of response is based on the RECIST amendments
† Tertiary endpoints include composite endpoints that are vulnerable in HCC research, such as disease-free and progression-free survival, that are difficult to measure with standard tools, such as time to symptomatic progression, or that are not time-to-event endpoints, such as response rate or disease control rate.
RECIST = Response Evaluation Criteria in Solid Tumors.
Llovet JM, et al. J Natl Cancer Inst. 2008;100:

6. Other recommendations of AASLD expert panel on HCC trial design
Target population
selection of the target population should be based on the Barcelona Clinic Liver Cancer staging system
new drugs should be tested in patients with well preserved liver function (Child–Pugh A class)
Control arm in clinical trials
patients assigned to the control arm should receive standard-of-care therapy, namely TACE for patients with intermediate-stage disease and sorafenib for patients with advanced-stage disease
Llovet JM, et al. J Natl Cancer Inst. 2008;100: 6 6 6

7. Conventional and proposed trial design in HCC trials
Trial phase and component
Conventional design
New proposed design
Phase 1
Study population
All cancers
HCC by Barcelona Clinic Liver Cancer (BCLC) Child–Pugh A
Study design
Phase 1/2
Aim
Dose defining
Safety
Endpoint
Toxic effects
Maximum tolerated dose, pharmacokinetics
Maximum tolerated dose and/or optimal biological dose
Phase 2
Unresectable HCC
Child–Pugh A and B
HCC by BCLC Child–Pugh A
Single arm
Randomized phase 2
Single arm*
Antitumor activity, safety
Response rate
Toxicity
Time to progression
Survival, toxicity
*Large single-arm phase 2 studies might only be considered when a contemporary historical control arm has been well characterized within other trials, and thus, inclusion criteria can be reproduced.
Llovet JM, et al. J Natl Cancer Inst. 2008;100:

8. Conventional and proposed trial design in HCC trials
Trial phase and component
Conventional design
New proposed design
Phase 3*
Study population
Unresectable HCC
Child–Pugh A and B
HCC by BCLC
Child–Pugh A
Study design**
Randomized controlled trial
Combined phase 2/3
Aim
Clinical outcome
Endpoint
Survival
Response
Progression-free survival, disease-free survival
Time to progression (TTP)
Recurrence***
*Large single-arm phase 2 studies might only be considered when a contemporary historical control arm has been well characterized within other trials, and thus, inclusion criteria can be reproduced.
** Consider phase 2/3 studies for fast-track approval with strong interim analysis.
*** Time to recurrence as primary endpoint in adjuvant trials.
Llovet JM, et al. J Natl Cancer Inst. 2008;100:

9. Selected targeted therapies under evaluation in advanced HCC: first-line therapy
Target population
Aim
Comparison
Phase
Status
Location
Advanced HCC1
Improve sorafenib
first line
Sorafenib +/– erlotinib
Phase 3
Recruiting
Global
Advanced HCC2
Compare with
sorafenib first line
Sorafenib vs linifanib
Advanced HCC3
Sorafenib vs brivanib
Regional/US
Advanced HCC4
sorafenib first line
Sorafenib vs erlot + beva*
Phase 2
Advanced HCC5
Sorafenib +/– everolimus
Phase 1/2
Active
Advanced HCC6
Sorafenib vs sunitinib
Terminated
Advanced HCC7,8
Sorafenib vs BIBF
Regional/Asia
Advanced HCC9
Sorafenib vs Dovitinb
Asia
Available from: Last accessed March SEARCH trial: NCT NCT BRISK FL trial: NCT NCT NCT NCT NCT NCT NCT
*Erlotinib + Bevacizumab 9 9

10. Selected targeted therapies under evaluation in advanced HCC: Second-line therapy
Target population
Aim
Comparison
Phase
Status
Location
Advanced HCC1
Second line after sorafenib
Brivanib vs placebo
Phase 3
Recruiting
Global
Advanced HCC2
Ramucirumab vs placebo
Advanced HCC3
Second line therapy
ADI-PEG 20 vs placebo
Not yet open US
Advanced HCC4
Everolimus vs placebo
Advanced HCC5
ARQ 197 vs placebo
Phase 2
Europ/US
Advanced HCC6
OSI-906 vs placenbo
Advanced HCC7
TAC-101 vs placenbo
Phase 1/2
Terminated
Italy
Available from: Last accessed March BRISK PS trial: NCT and BRISK-APS trial: NCT REACH trial: NCT
3. NCT EVOLVE-1 trial: NCT NCT NCT NCT 10 10

11. Molecular therapies tested in HCC
Regimen
Phase
Sample size
Response rate (%)
Progression-free survival/time to progression (months)
Median survival (months)
Reference
Sorafenib 3
300
2.3
5.5 (T)
10.7 (vs 7.9 placebo
Llovet et al.
271
2.8 (T)
6.5 (vs 4.2 placebo)
Cheng et al.
Sorafenib + doxorubicin 2b 47 4
8.6 (T)
13.7 (vs 6.5 placebo)
Abou-Alfa et al.
Sunitinib 2 37
2.7
5.2 (P)
11.2
Faivre et al. 34
2.9
3.9 (P)
9.8
Zhu et al.
Erlotinib 38 9
3.2 (P) 13
Philip et al. 40
3.1 (P)
6.3
10.75
Thomas et al.
Gefitinib 31
2.8 (P)
6.5
O’Dwyer et al.
Cetuximab 30
1.4 (P)
9.6 32
1.87 (T) –
Gruenwald et al.
Adapted from Finn RS. Clin Cancer Res. 2010;16:390-7. 11

12. Molecular therapies tested in HCC
Regimen
Phase
Sample size
Response rate (%)
Progression-free survival/time to progression (months)
Median survival (months)
Reference
Bevacizumab 2 46 13
6.9 (P)
12.4
Siegel et al.
Bevacizumab + erlotinib 40 25
9 (P)
15.65
Thomas et al.
Bevacizumab + gem+oxa* 30
5.3 (P)
9.6
Zhu et al.
Brivanib
First-line 55
2.8 (T) 10
Raoul et al.
Sec-line
2.7 (T)
9.8
Finn et al.
Linifanib 44
6,8
3,7 (T)
9,7
Toh et al.
Lapatinib 5
2,3 (P)
6,2
Ramanathan et al 26
1.9 (P)
12.6
Bekaii-Saab et al.
*gem=gemcitabine; Oxa=oxaliplatin
Adapted from Finn RS. Clin Cancer Res. 2010;16: Toh et al JCO 2009;27: 222s:abstr 4581; Ramanathan et al. Cancer Chem. Pharm. 2009;64:777-83 12

13. Sorafenib 400 mg b.i.d. + placebo
Sorafenib as adjuvant Treatment in the prevention Of Recurrence of hepatocellular carcinoMa (STORM)
Phase III, randomized, double-blind, placebo-controlled study of sorafenib +/- erlotinib in advanced metastatic patients
International (Europe, Americas, Asia-Pacific)
Advanced/ metastatic
Disease
Eligibility criteria
Child-Pugh A
PS 0 or 1
Endpoint
Primary OS
Secondary
TTP
DCR
PRO
Safety
Randomization
n=700
Stratification
ECOG PS
Geographic region
MVI/EHS
Sorafenib 400 mg bid +
erlotinib 150 mg daily
Sorafenib 400 mg b.i.d. + placebo
NCT
DCR = disease control rate; PRO = patient-reported outcome.
Reference
1. US National Institutes of Health; available at accessed November 2008.
2. Del Pozo AC, Lopez P. Clin Liver Dis 2007;11:305–321. 13

14. Sorafenib as adjuvant Treatment in the prevention Of Recurrence of hepatocellular carcinoMa (STORM)
Phase III, randomized, double-blind, placebo-controlled study of sorafenib as adjuvant treatment of HCC after surgical resection of local ablation
International (Europe, Americas, Asia-Pacific, Japan)
Prior treatment
Resection
RFA
PEI
Eligibility criteria
Child-Pugh
score 5–7
Intermediate/high risk of recurrence
Randomization
n=1,100
Stratification
Prior curative treatment
Geographical region
Sorafenib 400 mg bid
Endpoints
RFS OS
Biomarkers
Other
Placebo
RFA = radiofrequency ablation; PEI = percutaneous ethanol injection; RFS: recurrence-free survival.
NCT
Reference
1. US National Institutes of Health; available at accessed November 2008.
2. Del Pozo AC, Lopez P. Clin Liver Dis 2007;11:305–321. 14

15. Sorafenib or Placebo in combination with TACE in hepatocellular carcinoma (SPACE)
Phase II, randomized, double-blind, placebo-controlled study of TACE plus sorafenib vs TACE plus placebo
Eligibility criteria
BCLC B
ECOG PS 0
Child-Pugh Class A without ascite
No extrahepatic spread
No macrovascular invasion
Endpoints
Primary
TTP
Secondary OS
Time to untreatable progress
Time To Vascular Invasion
Time To Extrahepatic Spread R A N D O M I Z E
DC-Beads-TACE
+ Sorafenib 400 mg bid
n=300
DC-Beads-TACE
+ Placebo
1:1
TACE = transarterial chemoembolization;
TTP = time to progression; OS = overall survival.
Reference
1. US National Institutes of Health; available at accessed November 2008. 15

16. RTK: PDGFR FGFR VEGFR EGFR IGFIR c-MET Transcription/Translation
Signaling Pathways Provide Rationale for Combination Treatment Strategies
RTK: PDGFR FGFR VEGFR EGFR IGFIR c-MET
Receptor
Wnt Receptor
Cell Membrane X X
HBx
GEF
PTEN
GrB2
SHC
Site of action
DSH
PI3K
Ras
PLC X
Erlotinib Gefitinib
Lapatinib
Everolimus Sorafenib Sunitinib
GBP X
Akt
Raf
PKC X X
mTOR
MEK
GSK3
BAD X X
ERK
-Catenin
NF-κB X
BcL-XL
NF-κB
c-MYC
c-JUN
-Catenin X
p53
Survival
Transcription/Translation X
Anzola M. J Virol Hepat. 2004; 11: ; Avila MA, et al. Oncogene 2006; 25: ; Clauss M. Semin Thromb Hemost 2000; 26:
Avila MA, Berasain C, Sangro B, Prieto J. New therapies for hepatocellular carcinoma. Oncogene. 2006;25:
Clauss M. Molecular biology of the VEGF and the VEGF receptor family. Semin Thromb Hemost. 2000;26: 16

17. Molecular targets and targeted agents in HCC
Bevacizumab
VEGF
Ang1/2
HGF
EGF
AMG 386
PDGF
FGF
Ramucirumab
MEDI-575
Cetuximab
Sorafenib*
Sunitinib
Vatalanib
Cediranib
Pazopanib
Linifanib
E70807
Gefitinib
Molecular targets in the (a) epidermal growth factor (EGF) and EGF receptor (EGFR) family, (b) vascular endothelial growth factor (VEGF) and VEGF receptor (VEGFR) family, and (c) insulin-like growth factor (IGF) and IGF receptor (IGFR). Targeted agents are indicated by arrows.
ARQ 197
Erlotinib
Brivanib
Tie2
PDGFR
VEGFR
FGFR
C-Met
EGFR
Forentinib
XL 184
Regorafenib
BIBF 1120
SU6688
Sorafenib* is the only drug approved for HCC
Adapted from Tanaka S, Arii S. Cancer Sci. 2009;100:1-8
Adapted from Tanaka S, Arii S. J Gastroenterol 2011; in press *published online 25 Feb 2011 17

18. Molecular targets and targeted agents in HCCGF
RASSF1A
Ras
SOS
PTEN
Grb2
PI3K
PDK1
RTK
Akt
IKK
Sorafenib*
Raf
Regorafenib
Sirolimus
Everolimus
AZD8055
mTOR
AZD6244
MEK
eIF4E
4E-BP1
p70S6K
ERK
Sorafenib* is the only drug approved for HCC
Adapted from Tanaka S, Arii S. J Gastroenterol 2011; in press *published online 25 Feb 2011.

19. Molecular targets and targeted agents in HCC
Classification
Target
Sorafenib (Nexavar, BAY ; Bayer)
Small-molecule
VEGFR2, VEGFR3, PDGFR-b, Flt-3, c-KIT tyrosine kinase, Raf serine-threonine kinase
Regorafenib ( BAY ; Bayer)
VEGFR2, VEGFR3, PDGFR-b, Flt-3, c-KIT, Tie2 tyrosine kinase, Raf serine-threonine kinase
Sunitinib (Sutent, SU11248; Pfizer)
VEGFR1 VEGFR2, PDGFRs, Flt-3, c-KIT tyrosine kinase
Brivanib (BMS ; Bristol-Myers Squibb)
VEGFR2, VEGFR3, FGFR tyrosine kinase
BIBF 1120 (Vargatef; Boehringer Ingelheim)
VEGFR2, PDGFR-b, FGFR tyrosine kinase
SU6688 (TSU-68; Taiho)
Vatalanib (PTK787/ZK222584; Novartis)
VEGFR1, VEGFR2, VEGFR3,PDGFR-b, c-KIT tyrosine kinase
Cediranib (AZD2171; AstraZeneca)
VEGFR1, VEGFR2, VEGFR3, PDGFRs, c-KIT tyrosine kinase
Pazopanib (Votrient, GW786034; GlaxoSmithKline)
VEGFR-1, VEGFR-2, VEGFR-3, PDGFRs, c-KIT tyrosine kinase
Linifanib (ABT-869; Abbott)
VEGFR-2, PDGFR-b, CSF-1R tyrosine kinase
E7080 (Eisai)
VEGFR3, VEGFR2, VEGFR1 tyrosine kinase
Foretinib (XL880, GSK ; GlaxoSmithKline)
VEGFR-2, c-MET tyrosine kinase
XL184 (BMS907351; Bristol-Myers Squibb)
ARQ 197 (Daiichi Sankyo)
c-MET tyrosine kinase
Bevacizumab (Avastin; Roche/Genentech)
Monoclonal antibody
VEGF-A (neutralization)
Ramucirumab (IMC-1121B; Eli Lilly)
Monoclonal antibody VEGFR-2 (neutralization)
MEDI-575 (AstraZeneca)
PDGFR-a (neutralization)
AMG 386 (Amgen)
Antibody-type peptide
Angiopoietin-1, angiopoietin-2 (neutralization)
Adapted from Tanaka S, Arii S. J Gastroenterol 2011; in press *published online 25 Feb 2011.

20. Subway map HCC pathways
Dufour JF et al. J Hepatol. 2007; 47(6): 860-7

21. HCC transcriptome classification
BIOLOGICAL PATHWAYS
GROUPS
TREATMENTS
Developmental and imprinting genes,IGF2
Cell Cycle
Nucleus pore
Stress and immune response
Amino acid metabolism E-cadherin
Dufour J-F and Jonson P. J Hepatology J Hepatol. [Epub ahead of print] 21

22. Molecular classification of HCC HCC genomic-based classification
Molecular pathways
IFN
E2F p53
TGF-ß
Wnt
MYC
AKT
Retained hepatocyte-like phenotype
Published subclasse
EpCAM (+)
Proliferation
Clinical phenotype
Poor Survival
late TGF-ß
Good Survival
CTNNB1
Large tumor
Moderately/poorly differentiated
Smaller tumor
Well differentiated
AFT
In a meta-analysis of 603 HCC patients
3 HCC subtypes were observed, S1–S3
distinguished by molecular phenotype
correlated with tumor size, cellular differentiation, and serum α-fetoprotein levels
IFN = interferon; EpCAM = epithelial cell adhesion molecule.
Hoshida Y, et al. Cancer Res. 2009;69:

23. Outcome prediction in HCC
Model of HCC prognosis combining clinical and genomic data
In patients with early stage tumors, survival is mostly determined by genomic data coded in non-tumoral cirrhotic tissue (‘field effect’), because it determines the risk of liver dysfunction and development of a de novo HCC
As cancer progresses, genomic data from the tumor increases its prediction capacity because cancer-related death limits survival in patients with advanced disease
Very early
(Stage 0)
Single nodule < 2 cm,
no vascular invasion,
PST 0
Early
(Stage A)
Single nodule, 3 nodules < 3 cm,
no macrovascular invasion,
Intermediate
(Stage B)
Advanced
(Stage C)
Macrovascular invasion,
extrahepatic spread (N1, M1),
PST 1–2
Multiple nodules,
(BCLC algorithm)
Clinical stage
© 2010 American Association for Cancer Research`
De novo
tumor
Liver
dysfunction
Intrahepatic
dissemination
Tumor
biology
Others
Adjacent
tissue
Relative prognostic impact
of molecular data from tumor and adjacent tissue
Villanueva A, et al. Clin Cancer Res. 2010;16:

24. Translational research in HCC