Clinical trial NCT03956940: Analysis of cfDNA in Patients With Hepatocarcinoma and Treated by Sorafenib or Regorafenib
Official title: A Sorafenib-Regorafenib Sequence Treatment Monitoring Study Using Liquid Biopsy
Study type: INTERVENTIONAL
Overall status: TERMINATED
Phase: NA
Conditions: Hepatocarcinoma
Keywords: Hepatocarcinoma
cfDNA
intplex
Lead sponsor: Institut du Cancer de Montpellier - Val d'Aurelle
Sponsor class: OTHER
First posted: 2019-05-21
Enrollment: 18
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: DIAGNOSTIC

Brief summary: The aim of this trial is to investigate whether quantitative analysis of the total concentration of circulating free deoxyribonucleic acid (cfDNA) and of the cfDNA integrity index (DII) (Intplex®) may reflect hepatocellular carcinoma (HCC) tumor dynamics or response for patients treated by Sorafenib or Regorafenib and if it could be used as a tool for patient management under targeted therapy.

Detailed description: Circulating free deoxyribonucleic acid (cfDNA) is increasingly used in oncology with the aiml of early diagnosis of the disease, its therapeutic management and monitoring the evolution of the disease. Numerous publications have shown that the cfDNA concentration is correlated with the pathology of cancer. Larger amounts of cfDNA are detected in metastatic patients or patients with advanced cancer. However, the cfDNA concentrations have not yet shown their clinical interest mainly because of the variations in the same individual during the effort or the moment of collection of the blood sample. The concept of the integrity of cfDNA has also been studied as a biomarker in oncology and seems to show an interesting clinical value. The cfDNA is essentially released by cell apoptosis generating 170 bp fragments, corresponding to the size of a nucleosome. Many studies have shown that the integrity of cfDNA increases with the pathology of cancer. Thus, tumor-derived cfDNA is more fragmented than healthy cells with fragments smaller than the size nucleosome.

To date, no predictive biomarker is available for the management of treatment with Sorafenib which is a targeted therapy with a marketing authorization in first-line treatment of HCC (hepatocellular carcinoma) or second line with Regorafenib, treatment having shown a benefit positive on overall survival in the Resorce study. AFP (alpha-foetoprotein) is the only serum marker available with an inconstant increase in patients with HCC in fact only 30 to 40% of patients have abnormal values. In liver cancer, Ono et al showed that serum cfDNA is positively correlated with a larger tumor size.

This study shows that the rate of tumor cfDNA reflects the progression of the disease. Jiang et al showed that cfDNA derived from HCC is more fragmented than that derived from healthy cells, with fragments smaller than the size nucleosome.

These data demonstrate the potential utility of cfDNA amount and integrity as a biomarker for individualized management of hepatocellular carcinoma.

This new marker is expected to be an effective tool to overcome the lack of specificity of the AFP (alpha foetoprotein) assay in this pathology.

The investigator's team developed an Intplex® test that showed significant discrimination between healthy individuals and cancer patients.

The aim of this trial is to investigate whether quantitative analysis of the total concentration of cfDNA and of the cfDNA integrity index (DII) (Intplex®) may reflect HCC tumor dynamics or response for patients treated by Sorafenib or Regorafenib and if it could be used as a tool for patient management under targeted therapy.

Eligibility criteria: Inclusion Criteria:

1. Male or female patients ≥ 18 years of age
2. Histological or cytological documentation of hepatocellular carcinoma (HCC) or non-invasive diagnosis of HCC as per American Association for the Study of Liver Diseases (AASLD) criteria in patients with a confirmed diagnosis of cirrhosis
3. Patient treated for stage B hepatocellular carcinoma (multifocal disease) or stage C (metastatic disease) according to Barcelona Clinic liver cancer, regardless of treatment line, and that cannot benefit from local treatments such as resection, local ablation, chemoembolization
4. At least one uni-dimensional measurable lesion by computed tomography (CT) scan or magnetic resonance imaging (MRI) according to RECIST criteria 1.1 and modified RECIST for HCC
5. Liver function status Child-Pugh Class A
6. Eastern Cooperative Oncology Group (ECOG) Performance Status ≤ 1
7. Adequate bone marrow, liver and renal function as assessed by the following laboratory tests:

   * Hemoglobin \> 8.5 g/dL
   * Absolute neutrophil count ≥ 1500/mm3
   * Platelet count ≥ 60,000/ mm3
   * Total bilirubin ≤ 2 mg/dL
   * Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) ≤ 5 x upper limit of normal (ULN)
   * Serum creatinine ≤ 1.5 x Upper limit normal (ULN)
   * Lipase ≤ 2 x ULN
   * Prothrombin time-international normalized ratio (PT-INR) \< 2.3 x ULN and partial thromboplastin time (PTT) \< 1.5 x ULN
   * Glomerular Filtration Rate (GFR) ≥ 30 mL/min/1.73 m2
8. Life expectancy ≥ 3 months
9. Women of childbearing potential and men must agree to use adequate contraception
10. Patients must be affiliated to a Social Security System
11. Written informed consent signed

    Patients initially treated with Sorafenib, will be switched to Regorafenib if all the above conditions are still met and, in addition:
12. Documented progression under treatment with Sorafenib (defined as documented radiological and/or clinical and/or biological progression)

Exclusion Criteria:

1. Prior liver transplantation or candidates for liver transplantation
2. Hypersensitivity to the active substance or to any of the excipients
3. Patients with large esophageal varices at risk of bleeding that are not being treated with conventional medical intervention
4. Past or concurrent history of neoplasm other than HCC, except for in situ carcinoma of the cervix uteri and/or non-melanoma skin cancer and superficial bladder tumors. Any cancer curatively treated \> 3 years prior to study entry is permitted
5. Known history or symptomatic metastatic brain or meningeal tumors
6. Major surgical procedure or significant traumatic injury within 28 days before enrollment
7. Congestive heart failure New York Heart Association (NYHA) ≥ class 2
8. Unstable angina or myocardial infarction within the past 6 months before enrollment
9. Cardiac arrhythmias requiring anti-arrhythmic therapy
10. Uncontrolled hypertension
11. Patients with phaeochromocytoma
12. Uncontrolled ascites
13. Persistent proteinuria of NCI-CTCAE version 4.0 ≥ Grade 3
14. Ongoing infection \> Grade 2 according to NCI-CTCAE version 4.0. Hepatitis B is allowed if no active replication is required
15. Clinically significant bleeding NCI-CTCAE version 4.0 ≥ Grade 3 within 30 days before enrollment
16. Arterial or venous thrombotic or embolic events such as cerebrovascular accident, deep vein thrombosis or pulmonary embolism within 6 months before enrollment
17. Any psychological, familial, sociological, geographical or illness or medical condition that could jeopardize the safety of the patient and/or his compliance with the study protocol and follow-up procedure
18. Known history of human immunodeficiency virus (HIV) infection
19. Seizure disorder requiring medication
20. Non-healing wound, ulcer or bone fracture
21. Active autoimmune disease (lupus, sclerodermia, rheumatoid arthritis, ...)
22. Any malabsorption condition
23. Breast feeding
24. Pregnancy
25. High performance sport practice
26. Patient unable to swallow oral medication

    Patients who discontinue sorafenib will not be switched to regorafenib if any of the condition listed above occurs and/or the following criteria are met:
27. Prior discontinuation of prior Sorafenib therapy due to Sorafenib-related toxicity
28. Unresolved toxicity (Sorafenib) ≥ NCI-CTCAE version 4.0 Grade 2

Primary outcomes:
measure: Detection rate of total circulating free deoxyribonucleic acid (cfDNA) concentration at the baseline.
timeFrame: Baseline
Secondary outcomes:
measure: total circulating free deoxyribonucleic acid (cfDNA) fragmentation index
timeFrame: Baseline
measure: Objective response rate
timeFrame: Approximately 36 months
measure: Disease control rate
timeFrame: Approximately 36 months
measure: Progression-Free Survival
timeFrame: Approximately 36 months
measure: Time-to-progression
timeFrame: Approximately 36 months
measure: Overall Survival
timeFrame: Approximately 36 months
Other outcomes:
Locations:
city: Montpellier
country: France
facility: Hôpital Saint-Eloi
state: Hérault
city: Grenoble
country: France
facility: CHU Grenoble - Hôpital Michalon
state: Isère
city: Nantes
country: France
facility: Hôpital Hôtel Dieu
state: Loire-Atlantique
city: Vandœuvre-lès-Nancy
country: France
facility: CHRU Nancy - Hôpital Brabois
state: Meurthe Et Moselle
city: Lille
country: France
facility: CHRU de Lille - Hôpital Claude Duriez
state: Nord
city: Clichy
country: France
facility: Hôpital Beaujon
state: Seine-Saint-Denis
Study officials:
affiliation: Institut régional du cancer de Montpellier
name: Eric ASSENAT, MD
role: STUDY_CHAIR
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