Hepatic arterial infusion chemotherapy, lenvatinib plus programmed cell death protein‐1 inhibitors: A promising treatment approach for high‐burden hepatocellular carcinoma

Hepatic arterial infusion chemotherapy (HAIC) has demonstrated remarkable local therapeutic efficacy in treating patients with large unresectable hepatocellular carcinoma (HCC). Additionally, the combination of lenvatinib and programmed cell death protein‐1 (PD‐1) inhibitors has demonstrated promising antitumor effects in unresectable HCC. Therefore, we conducted a retrospective analysis to evaluate the efficacy and safety of combining HAIC with lenvatinib and PD‐1 inhibitors as a first‐line therapeutic approach in high‐burden HCC patients.


| INTRODUCTION
Primary liver cancer ranked as the sixth most prevalent cancer and the third leading cause of cancer-related deaths globally in 2020, registering approximately 906,000 novel diagnoses and 830,000 fatalities. 1 Hepatocellular carcinoma (HCC) accounted for 75%-85% of all primary liver cancer cases. 1 Despite the continuous improvement in liver cancer surveillance programs, the majority of patients are still diagnosed at advanced stages, rendering them ineligible for curative therapies. 2In a groundbreaking study, atezolizumab plus bevacizumab significantly extended the median overall survival (OS) among patients with unresectable HCC while maintaining a manageable toxicity profile. 35][6][7][8] These patients usually have a high intrahepatic tumor burden, and standard systemic therapies may not yield the desired antitumor response.
Hepatic arterial infusion chemotherapy (HAIC) is a locoregional interventional treatment method that allows for the direct administration of chemotherapeutic agents into tumor-feeding vessels.This approach theoretically leads to a greater intratumoral concentration of the chemotherapeutic agent, effectively reducing the tumor burden. 9Recent research has indicated that HAIC shows promise in terms of clinical efficacy for the treatment of advanced HCC characterized by major portal vein tumor thrombosis (PVTT) invasion (Vp3 and Vp4) and a high tumor burden. 7,10,11owever, there are currently no widely accepted standard regimens for HAIC in advanced HCC.4][15][16] Nevertheless, the survival advantage for patients administered MTA or ICI monotherapy remains relatively constrained.The future development direction for advanced HCC lies in combining MTAs with ICIs.A real-world retrospective study demonstrated the potent antitumor efficacy of combining lenvatinib, a molecular targeted agent, with programmed cell death protein-1 (PD-1) inhibitors in advanced HCC. 17 Furthermore, multiple investigations have suggested that combining HAIC with systemic therapy leads to better outcomes compared to using systemic therapy alone for high-burden patients with advanced HCC. 5,8 Hence, our aim was to retrospectively evaluate the effectiveness and safety of combining HAIC-FOLFOX with lenvatinib and PD-1 inhibitors as the first-line treatment for patients with high-burden HCC.

| Patient characteristics
Between November 2020 and June 2023, we screened electronic medical records of patients with advanced HCC who received first-line treatment with HAIC-FOLFOX in combination with lenvatinib and PD-1 inhibitors at the Second Affiliated Hospital of Nanchang University.We included consecutive patients based on the following specific criteria: Patients diagnosed with advanced HCC as per the American Association for the Study of Liver Disease (AASLD) practice guidelines 18 ; advanced HCC with tumor involvement of ≥50% of the liver and/or major PVTT, which includes thrombosis in the main trunk (Vp4) and the first-order branch of the portal vein (Vp3), graded following the 2010 guidelines of the Japan Society of Hepatology 19 ; no history of local interventional therapies or systemic therapies; at least one measurable lesion that can be evaluated using both the modified Response Evaluation Criteria in Solid Tumor (mRECIST) and RECIST version 1.1; Child-Pugh score ≤7; 18 years or older; and Eastern Cooperative Oncology Group Performance Status (ECOG-PS) of 0-1.The exclusion criteria included severe cardiovascular, pulmonary, or infectious diseases, as well as the concurrent presence of other malignant tumors.This study received approval from the Ethics Committee of the Second Affiliated Hospital of Nanchang University in China, and informed consent forms were signed by all participants.
artery with the guidance of digital subtraction angiography (DSA).Subsequently, the FOLFOX regimen was administered through the catheter.This regimen included oxaliplatin at a dose of 85 mg/m 2 infused over 3 h on Day 1, leucovorin at a dose of 400 mg/m 2 administered from 3 to 5 h on Day 1, and a 5-fluorouracil bolus at a dose of 400 mg/m 2 followed by a continuous infusion of 2400 mg/ m 2 over 46 h.Once the arterial chemotherapeutic drug infusion was completed, the catheter and sheath were removed.Lenvatinib and PD-1 inhibitors were administered within a 5-day window, either before or after the initiation of HAIC.Lenvatinib was administered orally at an initial dose of 12 mg per day for individuals with a body weight of 60 kg or more, and 8 mg per day for those with a body weight less than 60 kg until disease progression.In our initial exploratory study, we used multiple PD-1 inhibitors to ensure a larger sample size for investigating the effectiveness of combination immunotherapy.The PD-1 inhibitors, including tislelizumab (200 mg), sintilimab (200 mg), and camrelizumab (200 mg), were administered intravenously at their standard dosages.HAIC and PD-1 inhibitors were administered every 3 weeks, with PD-1 inhibitors continuing every 3 weeks after HAIC was discontinued.
The doses of lenvatinib and arterial chemotherapeutic agents could be adjusted, interrupted, or discontinued in response to treatment-related adverse events (TRAEs).All patients, including those who underwent liver resection, continued treatment until they experienced disease progression, encountered unacceptable toxicity, or until death occurred.The criteria for liver resection were based on the Chinese expert consensus on neoadjuvant and conversion therapies for hepatocellular carcinoma. 20atients eligible for liver resection met the following criteria: (1) demonstrated a reduction in tumor volume or tumor stage, achieving complete/partial response assessment, or maintaining stable disease for a minimum of 2 months based on mRECIST criteria.;(2) determined by multidisciplinary treatment (MDT) discussion, the tumor was deemed resectable with the possibility of achieving an R0 resection and sufficient residual liver volume and function; (3) had no contraindications for liver resection surgery.

| Data collection
We retrieved clinical and radiological data from electronic medical records, including the following information for analysis: age, gender, ECOG PS score, hepatitis etiology, alpha-fetoprotein (AFP) level, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), albumin (ALB), albumin bilirubin (ALBI) grade, maximum tumor size, tumor number, presence or absence of macrovascular invasion, classification of PVTT, and presence or absence of extrahepatic metastasis.All routine laboratory examination data were initially obtained within 1 week before the first treatment and subsequently at intervals of 3 ± 1 weeks during the treatment course.Imaging data, including magnetic resonance imaging (MRI) and contrast-enhanced computed tomography (CT) scans, were obtained within 1 week before the start of treatment, with subsequent evaluations conducted at intervals of 4-8 weeks.

| Outcome assessment
The primary endpoints of this study included progressionfree survival (PFS) and overall survival (OS), while the secondary endpoints encompassed the disease control rate (DCR), objective response rate (ORR), and TRAE.PFS was defined in this study as the time from the initiation of therapy to the first documented disease progression.For patients undergoing surgical resection, even if the entire tumor is completely excised, we opted not to censor these patients.Instead, they continued to be followed up, considering the time of surgery as the endpoint of observation, to ensure a comprehensive assessment of dynamic treatment response.OS was defined as the duration from the initiation of treatment to the time of death from any cause.Tumor response was categorized into complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD) based on assessments using both mRECIST and RECIST version 1.1 criteria.The ORR was calculated as the proportion of patients achieving a CR plus PR, while the DCR was determined by adding SD to the ORR.TRAEs were assessed following the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0.

| Statistical analysis
The statistical analyses were conducted using R software version 4.3.1 and IBM SPSS Statistics software version 25.0.Survival curves for PFS and OS were generated utilizing the Kaplan-Meier method.Variables with p-values less than 0.05 were deemed statistically significant in both univariate and multivariate Cox regression analyses.

| RESULTS
Between November 2020 and June 2023, we enrolled a total of 91 high-burden HCC patients who underwent treatment with HAIC-FOLFOX in combination with lenvatinib and PD-1 inhibitors (Figure 1).Detailed baseline patient characteristics are presented in Table 1.All participants had high-burden HCC, with 89% of them having major PTVTT (Vp3 or Vp4), 17.6% having extrahepatic metastasis, and 73.6% having a largest tumor diameter greater than 10 cm.The study included predominantly male participants (89%).Among the participants, hepatitis B virus (HBV) infection was the leading cause of HCC (94.5%), and all individuals with HBV-related HCC received antiviral therapy.

| Efficacy
The data cutoff time was June 15, 2023, and the median follow-up period was 16.3 months.As of the analysis, a total of 59 patients (64.8%) had experienced disease progression or mortality.The median PFS was 8.8 months (95% confidence interval [CI]: 5.75-11.78),as shown in Figure 2A, while the median OS was 14.3 months (95% CI: 11.23-17.31),as depicted in Figure 2B.During the study, a total of 285 HAIC cycles were administered, with a median of three cycles per patient.Tumor responses are summarized in Table 2.According to RECIST 1.1 criteria, none of the patients attained a CR.Out of the total number of patients, 48 (52.7%) attained PR, 39 (42.9%) had SD, and 4 (4.4%)experienced PD.The ORR was 52.7% and the DCR was 95.6%.According to mRECIST criteria, within the total patient cohort, 10 (11.0%) achieved CR, 56 (61.5%) attained PR, 21 (23.1%) had SD, and 4 (4.4%)experienced PD.The ORR was calculated to be 72.5%, and the DCR was 95.6%. Figure 3A,B illustrate the best change in the size of intrahepatic target lesions observed in the patients.The treatments, survival time, and tumor responses of all patients, ranked by the initial treatment time, are summarized in Figure 4.After the first-line treatment progression, 38 patients continued to receive subsequent therapies.Details of the follow-up treatments and the summary of patients undergoing local therapies are summarized in Table 3.

| Liver resection
In our study, a total of 18 patients underwent surgical intervention, meeting the criteria for surgical resection and expressing willingness to undergo surgical treatment.A detailed summary of baseline characteristics for both groups can be found in the Supplementary Material.Significantly, differences were observed pathological status of the 18 surgically treated patients are provided in Supplementary Material.The Kaplan-Meier survival curves for PFS and OS in both the resection and non-resection groups are presented in Figure 5 (Figure 5A,B).Given the relatively short follow-up duration, it is important to note that postoperative recurrence was not observed in over half of the patients in our cohort at the time of data collection.

| Prognostic factor analysis
The survival prognostic factors are presented in

| Safety
The frequencies of TRAEs have been tabulated in Table 5.Among all enrolled patients, 86 individuals (94.5%) experienced TRAEs, and no treatment-related deaths occurred during the course of therapy.three (3.3%)severe immune-related adverse events, including one case of Grade 3 immune-related pneumonia and two cases of Grade 3 immune-related hepatitis.For these patients, we implemented appropriate interventions, including the administration of corticosteroids or a combination of corticosteroids and immunosuppressants, resulting in symptom improvement.Additionally, during the arterial infusion of oxaliplatin, 36 (37.4%) patients experienced varying degrees of abdominal pain, including one patient who experienced Grade 3 abdominal pain.However, by reducing the infusion rate or temporarily discontinuing the administration of oxaliplatin and administering analgesics and lidocaine, the majority of patients rapidly obtained relief from pain.

| DISCUSSION
The prognosis of HCC with high-burden features (major PVTT [Vp3 and Vp4] and tumor infiltration of ≥50% of the liver) is extremely poor. 21,22Recently, two phase II clinical trials have demonstrated that the combination of HAIC with systemic therapy can lead to improved prognostic outcomes. 6,23Hence, we conducted this retrospective analysis to investigate the efficacy and safety of combining HAIC, lenvatinib, and PD-1 inhibitors for high-burden HCC in real-world settings.
Our study found that patients who received this combination achieved a median PFS of 8.8 months (95% CI, 5.75-11.78)and an OS of 14.3 months (95% CI, 11.23-17.31).Using RECIST 1.1 criteria, we observed an ORR of 52.7% and a DCR of 95.6%.Moreover, when assessed with mRECIST criteria, the ORR was 72.5%, with a corresponding DCR of 95.6%.These results suggest that triple therapy shows promise in delivering favorable therapeutic effects and enhancing survival outcomes for high-burden HCC patients.
The results of the REFLECT trial showed that in terms of OS, lenvatinib is non-inferior to sorafenib, with a median OS of 13.6 months. 14Consequently, lenvatinib has become the first-line treatment for patients diagnosed with advanced HCC.In our study, according to the mRECIST criteria, 10 (11.0%) patients achieved a CR, with an ORR of 72.5% and a DCR of 95.6%.In contrast, the REFLECT trial reported only 6 (1%) patients in the lenvatinib group achieving a CR, with an ORR of 24.1% and a DCR of 75.5%.Regarding survival outcomes, our study showed a median OS of 14.3 months, similar to the REFLECT trial.However, it is worth noting that our study population may have a poorer prognosis as we exclusively included patients with tumor involvement of more than 50% of the liver volume and major PVTT (Vp3 and Vp4), while the REFLECT trial excluded patients with liver involvement of more than 50% and those with main PVTT.Recently, the combination The best percentage change in size of intrahepatic target lesions relative to baseline in patients receiving HAIC combined with lenvatinib plus programmed cell death protein-1 inhibitors; mRECIST: modified response evaluation criteria in solid tumors; RECIST, response evaluation criteria in solid tumors.therapy of atezolizumab and bevacizumab has emerged as a huge breakthrough in the systemic treatment of advanced HCC. 3 Nonetheless, the updated IMbrave150 study revealed limited therapeutic benefits for patients with extensive liver involvement (more than 50% of the liver) and Vp4 portal vein tumor thrombus, with a median OS of just 7.6 months. 4In comparison, our study participants achieved a significantly higher OS compared to patients in the IMbrave150 trial who had Vp4 portal vein thrombus, bile duct invasion, or tumor involvement exceeding 50% of the liver volume.Although our study population differed from the subgroup in IMbrave150, there is evidence indicating poor prognosis in patients with major PVTT. 24 randomized Phase II trial comparing the effectiveness of combining HAIC with sorafenib versus sorafenib alone in patients with major PVTT showed slightly superior OS and PFS outcomes in the HAIC combination group compared to our combination therapy of HAIC with lenvatinib and PD-1 inhibitors.6 In our study, multivariate  analysis identified independent factors for PFS, including ECOG PS score, number of tumors, and presence of extrahepatic metastasis.Similarly, in the multivariate analysis of OS, independent risk factors were the Child-Pugh score, number of tumors, and presence of extrahepatic metastasis.Compared to this Phase II trial, our patients had higher ECOG PS scores, a greater number of tumors, and more cases of extrahepatic metastasis.These factors might partially explain the persistently poor prognosis despite the addition of PD-1 inhibitors.However, our study demonstrated a superior ORR and DCR according to both RECIST 1.1 and mRECIST criteria compared to the Phase II trial.The observed survival benefits and excellent antitumor effects in our study can be attributed to a multitude of factors.First, the utilization of this triple combination therapy, which includes HAIC-FOLFOX, lenvatinib, and PD-1 inhibitors, holds the potential to elicit synergistic antitumor effects. O the one hand, HAIC can rapidly reduce tumor burden and improve patients' tolerance to systemic treatment, and thus prolong treatment duration.6 On the other hand, lenvatinib, a multitarget tyrosine kinase inhibitor (TKI), inhibits VEGFRs and FGFR, altering the tumor microenvironment (TME) and potentially enhancing the response to immunotherapy.[25][26][27][28] Additionally, oxaliplatin can induce immunogenic cell death also contributes to the enhanced response to immunotherapy.29 Second, in our study, a total of 18 patients underwent surgical resection, and Kaplan-Meier survival curves demonstrated a significant improvement in both PFS (p = 0.009) and OS (p = 0.006) in the resection group compared to the non-resection group.Despite baseline differences in ALBI between the resection and non-resection groups, Cox analysis, encompassing both univariate and multivariate analyses of PFS and OS, indicated that the impact of ALBI may not reach statistical F I G U R E 5 Kaplan-Meier curves for progression-free survival and overall survival in the resection group and nonresection group.significance.This result suggests that although there are some differences in ALBI between the surgical and nonsurgical groups, the influence may be relatively limited in survival analyses.Recent research suggests that the combination of TKI combined immunotherapy holds promise in increasing the likelihood of surgical resection for HCC patients initially deemed unsuitable for surgery.30,31 These findings underscore the potential for transformative responses and conversion rates in unresectable HCC.Although prior studies have demonstrated poorer short-term and long-term outcomes for patients with major PVTT after surgical intervention, a retrospective study by Hamaoka et al. involving HCC patients with PVTT showed that among the 52 patients receiving combined HAIC and radiotherapy, 7 patients underwent surgical intervention.The study revealed a significantly improved overall survival in the resection group compared to the non-resection group suggesting that HAIC-based therapy might enhance the likelihood of curative resection, particularly in high-burden patients.[32][33][34] Regarding TRAEs, most of patients in our study experienced varying grades of TRAEs, which were generally manageable and did not result in TRAE-related deaths.In contrast to the REFLECT study, we observed a higher occurrence of proteinuria, but the majority of cases were Grades 1-2 and did not significantly impact the treatment.14 Additionally, liver function abnormalities associated with TRAEs were also common but improved rapidly after completing HAIC and receiving hepatoprotective treatment.Abdominal pain was another common phenomenon, primarily occurring during arterial infusion of oxaliplatin.By reducing the infusion rate or temporarily stopping the administration of oxaliplatin, and providing analgesics and lidocain, the majority of patients experienced rapid pain relief.It is worth noting that during the treatment period, 4 patients experienced Grade 3 esophagogastric variceal bleeding, which may have been due to their pre-existing severe liver cirrhosis.Although timely endoscopic variceal ligation effectively managed the bleeding, regular endoscopic examinations may be necessary for patients with severe liver cirrhosis to assess esophagogastric varices and intervene early.In our study, we observed three severe immune-related adverse events, including one case of Grade 3 immune-related pneumonia and two cases of Grade 3 immune-related hepatitis.Among them, one patient with immune-related pneumonia and one with immune-related hepatitis showed symptom improvement after receiving intravenous methylprednisolone at a dose of 1 milligram per kilogram of T A B L E 5 Treatment-related adverse events.

T A B L E 4
body weight.However, for a patient with immune-related hepatitis, despite receiving the same dose of methylprednisolone, liver function continued to deteriorate.Subsequent improvement was achieved after the addition of the immunosuppressant mycophenolate mofetil at a daily dose of 500 milligrams.In the current landscape of immunotherapy, vigilant monitoring of immune-related adverse events is paramount, as these severe events can rapidly worsen, necessitating timely identification and appropriate intervention.First, it is important to note that this is a retrospective study with a relatively small sample size and lacks a control group for comparison.Therefore, the possibility of selection bias cannot be ruled out.Second, it is essential to emphasize that in our study, the primary underlying cause among patients is infection with the hepatitis B virus (HBV), a distinctive feature not shared with regions such as the United States, Europe, and Japan. 35Concurrently, compared to global patient cohorts, Chinese patients manifest a higher incidence of microvascular invasion (MVI) and/or extrahepatic spread (EHS).Additionally, a greater proportion of Chinese patients are categorized into Barcelona clinic liver cancer (BCLC) stage C, indicating a more advanced clinical stage. 36Therefore, further research is required to explore the applicability of triple therapy for other types of hepatitis.Third, it is crucial to consider variations among PD-1 inhibitors, as these could potentially impact patient responses and outcomes.Our center is currently conducting a unified protocol to further explore the efficacy of triple therapy.Lastly, considering the retrospective design of this study, there is a potential that adverse events may not have been thoroughly documented.Consequently, it is important to exercise caution when interpreting the findings of this study.
In conclusion, the utilization of HAIC-FOLFOX in combination with lenvatinib and PD-1 inhibitors as firstline treatment shows significant promise for high-burden HCC patients, with manageable adverse events.Thus, this combination therapy of HAIC, lenvatinib, and PD-1 inhibitors represents a promising and innovative treatment option for high-burden HCC.However, further prospective randomized controlled trials are necessary to validate above conclusions.
241 patients with unresectable HCC who underwent HAIC combined with lenvatinib plus PD-1 inhibitors between November 2020 to June 2023 Excluded (n=103) Received other systemic treatment(n=88) Combined with other malignant tumors (n=4) No intrahepatic measurable lesions(n=11) 138 patients underwent HAlC combined with lenvatinib plus PD-1 inhibitors as as first-line treatment Excluded(n=47) Incomplete medical information (n=16) Lost to follow-up(n=12) Inconsecutive treatment (n=19) 91 eligible patients received HAlC combined with lenvatinib plus PD-1 inhibitors as as first-line treatment exclusively in the two groups prior to ALBI, with no discernible distinctions in other baseline indicators.Additional comprehensive details on the treatment plans, baseline information, and postoperative

F I G U R E 4
Treatments, survival, and tumor response of all patients, ranked by initial treatment time, evaluated by modified response evaluation criteria in solid tumors.T A B L E 3 Subsequent treatments.

Table 4 .
In the analysis of PFS, univariate analysis indicated significant associations between PFS and ECOG PS, liver cirrhosis, tumor number, and extrahepatic metastasis.
Baseline characteristics of patients.
Additionally, 4 patients (4.4%) had Grade 3 esophageal variceal bleeding, and timely endoscopic band ligation and hemostasis led to successful recovery.In terms of adverse events related to immunotherapy, we observedT A B L E 1 Univariate and multivariate analysis of progression-free survival and overall survival.