Targets of immunotherapy for hepatocellular carcinoma: An update

Table 1 Immune checkpoint inhibitor therapy for hepatocellular carcinoma

Immune checkpoint inhibitor therapy
Agent	Type of study	Study details	Outcome
Tremelimumab (anti-CTLA4)[45]	Phase II clinical trial	21 HCC patients infected with hepatitis C virus and not eligible for surgery or locoregional therapy 15 mg/kg IV every 90 d	17.6% patients-partial response; 58.8% patients-stable disease; Time to progression-6.48 mo; Overall survival-8.2 mo; Decreased viral load
TRC105 (carotuximab) antibody to CD105[46]	Phase I/II study	TRC105 (15 mg/kg) every 2 wk given with sorafenib 400 mg twice daily	Tumor ablation utilizing RFA and TACE enhance the efficacy of tremelimumab; Improves intratumoral effector CD8+ T cells infiltration
Nivolumab (anti-PD-1)[47]	CheckMate 040 phase I/II dose-escalation study	182 patients with advanced HCC; Patients naive to or previously treated with sorafenib received 0.1-10 mg/kg and 3 mg/kg once every 2 wk	Durable responses with long-term survival and favorable safety in both sorafenib-naive and -experienced patients; 3.8% complete response, 14.8% partial response, and 62.6% disease control rate
Nivolumab (anti-PD-1)[33]	Phase I/II study NCT01658878	262 HCC patients; HCC patients on sorafenib	1.4% complete response; 18.2% partial response; 83% overall survival at 6 mo
Pembrolizumab (anti-PD-1)[48]	KEYNOTE-224 trial	104 advanced HCC patients on sorafenib	1% complete response; 16% partial response; 54% overall survival at 12 mo
Durvalumab (PD-L1) and tremelimumab (CTLA4)[49]	Phase I/II, open-label, randomized study	For the efficacy of durvalumab combined with tremelimumab in unresectable HCC	No unexpected safety signals with durvalumab and tremelimumab seen in unresectable HCC patients
Tremelimumab (CTLA4)[50]	Phase II trial NCT01853618	32 patients with HCC with HCV; Tremelimumab at 3.5 and 10 mg/kg i.v. every 4 wk for 6 doses, followed by 3-monthly infusions; Combined with subtotal radiofrequency ablation or chemoablation at day 36	No dose-limiting toxicities; Accumulation of intratumoral CD8+ T cells; 26% partial response

CTLA-4: Cytotoxic T lymphocyte protein 4; PD-1: Programmed cell death protein 1; HCC: Hepatocellular carcinoma; HCV: Hepatitis C virus; RFA: Radiofrequency ablation; TACE: Transarterial chemoembolization.

Table 2 Ongoing clinical trials for immune checkpoint inhibitor therapy

Identifier	Type of study	Study design	Status/outcome
NCT02576509 (CheckMate-459)	Global phase III randomized control trial	Comparing nivolumab with sorafenib as first treatment in advanced HCC	Recruitment closed; Results awaited
NCT01658878	Phase I/II dose-escalation, open-label, non-comparative study	Phase 1 to establish the safety of nivolumab at different dose; Phase 2 to compare the efficacy of nivolumab and sorafenib; To study the safety and efficacy of the combination of nivolumab plus ipilimumab and nivolumab plus cabozantinib	Active, not recruiting
NCT03298451	Randomized phase III HIMALAYA trial	To compare the combination of tremelimumab (CTLA-4 inhibitor) and durvalumab (PD-L1 inhibitor) vs sorafenib	Recruiting patients
NCT03680508	Phase II trial	To test efficacy of TSR-022 (cobolimab, TIM-3 binding antibody) and TSR-042 (dostarlimab, PD-1 binding antibody) on advanced HCC	Recruiting patients
NCT02947165	Phase I/Ib study	Anti-TGF-β monoclonal antibody NIS793 and PD-1 inhibitor spartalizumab in breast, lung, colorectal, pancreatic, renal, and HCC	Active, not recruiting
NCT03412773	Phase III randomized, open-label, multicenter, global study	To compare the efficacy and safety of tislelizumab vs sorafenib in unresectable HCC	Active, not recruiting
NCT03434379 (IMbrave150)[51]	Phase III study	To evaluate the efficacy and safety of atezolizumab in combination with bevacizumab compared with sorafenib in locally advanced or metastatic HCC; To determine overall survival	Atezo + Bevac showed improved survival at 18 mo (52%) with clinically meaningful treatment benefit and safety. The trial confirmed atezo + bevac as a standard of care for previously untreated, unresectable HCC
NCT02702401 (MK-3475-240/KEYNOTE-240)	Phase III study	Pembrolizumab (MK-3475) in advanced HCC treated systemically as a second line therapy; To determine overall survival and progression free survival	Active, not recruiting
NCT03062358 (MK-3475-394/KEYNOTE-394)	Phase III study	To determine the efficacy and safety of pembrolizumab or placebo with best supportive care previously systemically treated HCC	Active, not recruiting
NCT03383458 (CheckMate 9DX)	Phase III study	To investigate if nivolumab will improve recurrence-free survival compared to placebo in HCC undergone complete resection	Active, not recruiting

CTLA-4: Cytotoxic T lymphocyte protein 4; PD-1: Programmed cell death protein 1; HCC: Hepatocellular carcinoma; TGF: Transforming growth factor; TIM3: T cell immunoglobulin and mucin domain-containing protein 3.

Table 3 Adoptive cell therapy for hepatocellular carcinoma

Adoptive cell transfer
Agent	Type of study	Study details	Outcome
NK cells stimulated with IL-2[60]	Phase I trial	Patients with liver cirrhosis with HCC undergoing liver transplantation	Upregulation of peripheral NK cell cytotoxicity, no adverse events
CIK cell therapy as adjuvant to RFA[61]	A multicenter, randomized, open label phase III trial	230 HCC patients; CIK cell therapy as adjuvant to RFA, ethanol injection or curative resection	An improvement of 14 mo in recurrence free survival
Autologous TILs[62]	Phase I trial	15 patients with HCC post-resection	Successful expansion of TILs in 88% without any evidence of disease; No serious adverse events
GPC3 CAR-T[63]	Phase I trial	13 Chinese patients with r/r GPC3+ HCC	Feasible and safe for Chinese pts with r/r GPC3+ HCC; Promising antitumor potential when LDC is applied along with GPC3 CAR-T

NK: Natural killer; IL: Interleukin; HCC: Hepatocellular carcinoma; CIK: Cytokine-induced killer; TIL: Tumor-infiltrating lymphocytes; RFA: Radiofrequency ablation; CAR: Chimeric antigen receptor.

Table 4 Clinical trials on adoptive cell transfer therapy

Clinical trials #	Phase	Aim and design	Status
NCT03563170	Phase 1b/2	Combining innate high-affinity natural killer (hank) cell therapy with adenoviral and yeast-based vaccines to induce t-cell responses vs sorafenib	Withdrawn
NCT03008343	Phase I/II	Combination of IRE and NK cells immunotherapy vs IRE alone	Completed, no result posted
NCT01147380	Phase I	Natural killer cell therapy for hepatoma liver transplantation (MIAMINK); To evaluate feasibility and safety of the adoptive transfer of activated NK cells	Completed; No adverse events reported
NCT02008929	Phase II	To evaluate the safety and efficacy of injecting MG4101 (ex vivo expanded allogeneic NK cell) as a secondary treatment after curative liver resection in advanced HCC	Completed; No study results posted
NCT01749865	Phase III	CIK treatment in 200 patients with HCC who underwent radical resection	Completed; No study results posted
NCT02723942	Phase I/II	To evaluate the safety and efficacy of CAR-T cell immunotherapy for GPC3 positive hepatocellular carcinoma	Withdrawn due to revision of local regulations
NCT03198546	Phase I	GPC3 and/or TGF-β targeting CAR-T cells in	Recruiting
NCT03130712	Phase I/II	GPC3-targeted T cells by intratumor injection for advanced HCC (GPC3-CART)	Unknown
NCT02715362	Phase I/II	GPC3 redirected autologous t cells for advanced HCC (GPC3-CART)	Unknown
NCT03013712	Phase I/II	GPC3-targeted T cells by intratumor injection for advanced HCC (GPC3-CART)	Unknown
NCT03349255	Phase I	Autologous ET1402L1-CAR T cells in AFP expressing HCC	Terminated and will study new T-cell construct
NCT02905188	Phase I	To find the biggest dose of GLYCAR T cells that is safe, to see how long they last in the body, to learn what the side effects in GPC3-positive HCC	Recruiting patients; Partial response with no toxicities
NCT03146234	Single arm, open-label pilot study	to determine the safety and efficacy of CAR-GPC3 T cells in patients with relapsed or refractory HCC following cyclophosphamide and fludarabine	Completed; Had a tolerable toxicity profile with no grade 3/4 neurotoxicity; Overall survival 9.1
NCT02395250	Phase I	To evaluate the safety and effectiveness of anti-GPC3 CAR T in patients with relapsed or refractory HCC	Completed, no result posted
NCT03980288	Phase I	4th generation chimeric antigen receptor T cells targeting glypican-3 (CAR-GPC3 T cells) in patients with advanced HCC	Recruiting patients
NCT04121273	Phase I	GPC3-targeted CAR-T cell for treating GPC3 positive advanced HCC	Recruiting patients
NCT03884751	Phase I	Clinical study of chimeric antigen receptor T cells targeting glypican-3 (CAR-GPC3 T cells) in patients with advanced HCC	Recruiting patients
NCT04093648	Phase I	T cells co-expressing a second generation glypican 3-specific chimeric antigen receptor with cytokines interleukin-21 and 15 as immunotherapy for patients with liver cancer (TEGAR)	Withdrawn (the key elements of this study were incorporated into another study)
NCT03013712	Phase I/II	CAR T cells targeting EpCAM positive cancer (CARTEPC); To evaluate the safety and efficacy of chimeric antigen receptor (CAR) T cells targeting EpCAM	Unknown

NK: Natural killer; IL: Interleukin; HCC: Hepatocellular carcinoma; CIK: Cytokine-induced killer; TIL: Tumor-infiltrating lymphocytes; RFA: Radiofrequency ablation; CAR: Chimeric antigen receptor; Adenoviral and Yeast based vaccines: ETBX-011, GI-4000, avelumab, Aldoxorubicin hydrochloride, ETBX-051, ETBX-061, GI-6207, GI-6301, and N-803; IRE: Irreversible electroporation; LDC: Lymphodepleting conditioning; GLYCAR: Glypican 3-specific chimeric antigen receptor expressing T cells for hepatocellular carcinoma; HCC: Hepatocellular carcinoma.

Table 5 Vaccine therapy for hepatocellular carcinoma

Vaccine	Phase	Study design	Outcome
Autologous dendritic cells (DCs) generated ex vivo in the presence of GM-CSF and IL-4[70]	Phase I	10 patients with unresectable primary liver cancer	Immunization well tolerated without significant toxicity
Mature autologous DCs[71]	Phase II	To investigate the safety and efficacy of intravenous vaccination	Safe and well tolerated with evidence of antitumor efficacy
Ilixadencel (pro-inflammatory allogeneic DCs stimulated by GM-CSF and IL-4)[72]	Phase I trial	17 HCC patients; As monotherapy or in combination with sorafenib to evaluate tolerability	Increased tumor specific CD8+ T cells in peripheral blood (73%); 1 grade 3 adverse event
GPC3 peptide[67]	Open-label, phase I clinical trial	33 patients with advanced HCC; To evaluate safety of GPC3 peptide, immune response, tumor response, time to tumor progression, and overall survival	GPC3 vaccination was well-tolerated; 1 patient partial response; 19 patient stable disease; 2 mo after vaccination; Measurable immune responses and antitumor efficacy
Pexa-Vec (modified poxvirus JX-594)[73]	Randomized phase II dose-finding trial	30 patients with advanced HCC; 3 intra-tumoral injections; To determine the optimal JX-594 dose	Dose related survival benefit; Increased median survival of 14.1 mo compared to 6.7 mo
Pexa-Vec (JX-594)[74]	Phase 2, open-label, randomized dose finding study	Patients with advanced HCC; Intra-tumoral injection 3 times every 2 wk
Pexa-Vec (pexastimogene devacirepvec) followed by sorafenib[75]	Global, randomized, open-label phase III trial (PHOCUS)	459 patients will be recruited; To evaluate overall survival, time to progression, progression-free survival, overall response rate and disease control rate	Trial completed; 5% adverse events

IL: Interleukin; GM-CSF: Granulocyte-macrophage colony-stimulating factor; HCC: Hepatocellular carcinoma.

Table 6 Ongoing clinical trials on vaccine therapy for hepatocellular carcinoma

Clinical trial #	Phase	Agent/vaccine	Design/aim	Status
NCT01974661	Phase I	COMBIG-DC (ilixadencel)	Is it possible to inject the COMBIG-DC vaccine in a hepatic tumor without getting unacceptable side effects	Completed; No results posted
NCT01821482	Phase II	DC-CIK	To evaluate the efficacy of DC-CIK for HCC	Unknown/not yet recruiting
NCT02638857	Phase I/II	DC precision multiple antigen T cell	To evaluate the safety and efficacy of dendritic cell-precision multiple antigen T cells with TACE in HCC	Unknown/was recruiting
NCT02882659	Phase I	Autologous dendritic killer cell	To evaluate the safety in patients with metastatic solid tumor; To evaluate the maximum tolerated dose	Unknown/was active, not recruiting
NCT03674073	Phase I	Personalized neoantigen-based dendritic cell	A single institution, open-label, multi-arm, pilot study; DC vaccine combined with microwave ablation in HCC	Unknown/was recruiting
NCT03203005	Phase I/II	Cancer vaccine called IMA970A combined with CV8102	To investigate the safety; To check if this combination can trigger an immune response against the tumor in HCC	Completed; No results posted
NCT02562755	Phase III	Pexastimogene devacirepvec (Pexa Vec) and sorafenib	To investigate if the combined treatment increases survival compared to treatment with sorafenib alone in HCC	Completed

DCs: Dendritic cells; CIK: Cytokine-induced killer; HCC: Hepatocellular carcinoma.

Table 7 Ongoing clinical trial for combination therapy for hepatocellular carcinoma

Immune checkpoint/vaccine therapy	Radiotherapy/other therapy	Phase	Study design	Status	Trial ID
Ipilimumab	Nivolumab	Phase I/II	To assess the effects of combination treatment with nivolumab and ipilimumab pre-operatively in HCC	Recruiting patients	NCT03682276
Nivolumab	Ipilimumab	Phase I	To compare the overall survival of nivolumab plus ipilimumab vs standard of care (sorafenib or lenvatinib) in patients with advanced HCC	Recruiting patients	NCT04039607
Nivolumab	Ipilimumab	Phase II	Nivolumab plus Ipilimumab as neoadjuvant therapy for HCC; To test efficacy, tumor shrinkage, and objective response rate	Recruiting patients	NCT03510871
Nivolumab	Ipilimumab	Phase II	Nivolumab with or without ipilimumab in treating patients with resectable liver cancer		NCT03222076
Nivolumab, ipilimumab	SBRT	Phase I	To determine the safety and tolerability of SBRT followed by nivolumab or ipilimumab in HCC	Active, not recruiting	NCT03203304
Pembrolizumab	Talimogene laherparepvec (genetically modified oncolytic viral therapy)	Phase Ib/II	Multicenter, open-label, basket trial; To evaluate the safety of talimogene laherparepvec injected intra-hepatically into liver tumors alone and in combination with systemic IV administration of pembrolizumab	Recruiting patients	NCT02509507; MK-3475-611/Keynote-611 (MASTERKEY-318)
Nivolumab	Pexa-Vec	Phase I/II	To evaluate the safety and efficacy in HCC	Active, not recruiting	NCT03071094
Modified vaccinia virus ankara vaccine expressing p53	Pembrolizumab	Phase I	To study the side effects of vaccine therapy and in treating patients with solid tumors with metastasis	Active, not recruiting	NCT02432963
GNOS-PV02 (personalized neoantigen DNA vaccine)	Plasma encoded IL-12 (INO-9012) pembrolizumab	Phase I/IIa	A single-arm, open-label, multi-site study of GNOS-PV02 and INO-9012 in combination with pembrolizumab (MK-3475) in histologically or cytologically confirmed HCC	Recruiting patients	NCT04251117
DNAJB1-PRKACA fusion kinase peptide vaccine	Nivolumab and Ipilimumab	Phase I	To study the safety and tolerability of administering a vaccine targeting the DNAJB1-PRKACA fusion kinase, in combination with nivolumab and ipilimumab in unresectable or metastatic fibrolamellar HCC	Recruiting patients	NCT04248569
Durvalumaband tremelimumab	Sorafenib	Phase III	To assess the efficacy and safety of durvalumab plus tremelimumab combination therapy and durvalumab monotherapy vs sorafenib in the treatment of patients with no prior systemic therapy for unresectable HCC		NCT03298451
TremelimumabDurvalumab (MEDI4736)	Radiation therapy	Phase II	To test the combination therapy as a possible treatment for HCC or biliary tract cancer	Recruiting patients	NCT03482102
Nivolumab	Y90-radioembolization	Phase II	To evaluate the response rates of Y90 radioembolization in combination with nivolumab in HCC	Recruiting patients	NCT03033446
Ipilimumab	SBRT	Phase I	To find the highest tolerable dose of ipilimumab and SBRT in liver and lung cancer	Completed but no results posted	NCT02239900
Nivolumab	TACE	Phase II (IMMUTACE)	To evaluates the safety and the efficacy of nivolumab in combination with TACE in patients with multinodular, intermediate stage HCC as first line therapy	Active, not recruiting	NCT03572582
Pembrolizumab	TACE	Phase I/II (PETAL)	Open label, single arm, multi-centre study; To determine the safety and tolerability of pembrolizumab following TACE	Recruiting patients	NCT03397654
Durvalumab; Tremelimumab	TACE; RFA; Cryoablation	Phase II	To evaluate the 6-mo progression free survival with combination therapy in patients with HCC	Recruiting patients	NCT02821754
Immune Checkpoint Inhibitor	TACE; SBRT	Phase II; START-FIT	Sequential TACE and SBRT with immunotherapy	Recruiting patients	NCT03817736
Durvalumab	Tremelimumab	Phase II	To evaluate the safety, tolerability, antitumor activity, pharmacokinetics, pharmacodynamics, and immunogenicity of durvalumab or tremelimumab monotherapy, or durvalumab in combination with tremelimumab or bevacizumab in advanced HCC; Initial reports of concerns with safety and efficacy of the combination of durvalumab and tremelimumab in HCC	Active, not recruiting	NCT02519348

SBRT: Stereotactic body radiotherapy; TACE: Trans-arterial chemoembolization; HCC: Hepatocellular carcinoma; RFA: Radiofrequency ablation.