Efficacy and safety of sequential therapy with sorafenib and regorafenib for advanced hepatocellular carcinoma: a two-center study in China

Abstract

Background: Regorafenib is a standard 2nd-line treatment for patients with advanced hepatocellular carcinoma (HCC), but the efficacy and safety of sequential therapy with sorafenib and regorafenib among advanced HCC patients in China is not clear.

Methods: This was a retrospective, two-center, cohort study of advanced HCC patients who received sequential therapy of sorafenib and regorafenib from October 2018 to April 2020 at 2 Chinese institutions. The patients were converted directly to regorafenib after failing to respond to sorafenib monotherapy. The patients underwent evaluations every 4-6 weeks to determine the efficacy and safety of the treatment according to physiological, laboratory, and radiological results. A radiological evaluation using computed tomography or magnetic resonance imaging scans was conducted. The outcomes included overall survival (OS) and progression-free survival (PFS).

Results: A total of 43 patients received regorafenib as a 2nd-line treatment after sorafenib progression. Of these patients, 26 (60.5%) and 17 (39.5%) were diagnosed with Barcelona Clinic Liver Cancer (BCLC) stages B and C, respectively. The median PFS was 11.0 [95% confidence interval (CI): 5.8-16.2] months, and the median OS was 17.0 (95% CI: 12.8-21.2) months. Conversely, the most common toxicities were hand-foot skin reaction (48.8%), diarrhea (32.6%), and hypertension (14%). The most common grade 3-4 toxicities were hypoalbuminemia (4.7%), anemia (4.7%), and thrombocytopenia (4.7%). Alpha-fetoprotein (AFP) ≥400, alanine transaminase (ALT) ≥60 IU/L, and aspartate aminotransferase (AST) ≥60 IU/L before 2nd-line treatment were associated with PFS in the univariable analyses. The Cox proportional-hazards regression analysis showed that AFP [hazard ratio (HR) =0.225; 95% CI: 0.073-0.688; P=0.009], ALT (HR =0.195; 95% CI: 0.051-0.741; P=0.016), AST (HR =0.209; 95% CI: 0.063-0.697; P=0.011), and presence of extrahepatic metastasis (HR =0.074; 95% CI: 0.009-0.608; P=0.015) before 2nd-line treatment were independently associated with PFS.

Conclusions: The sequential therapy of sorafenib and regorafenib is well-tolerated and effective in advanced HCC patients after sorafenib progression based on our two-center real-world data. Patients with good liver function reserve and a high level of AFP before 2nd-line treatment may benefit from sequential treatment. These results still need further validation.

Keywords: Hepatocellular carcinoma (HCC); RESORCE; regorafenib; sequential therapy; sorafenib.

Figure 1

Kaplan-Meier analysis of the PFS (A) and OS (B) of HCC patients treated with regorafenib after sorafenib. PFS, progression-free survival; OS, overall survival; HCC, hepatocellular carcinoma.

Figure 2

Subgroup survival analysis of the PFS of HCC patients treated with regorafenib after sorafenib. (A) Kaplan-Meier curve of the PFS of HCC patients treated with regorafenib after sorafenib for the <400 and ≥400 ng/mL AFP groups before 2nd-line treatment; (B) Kaplan-Meier curve of the PFS of HCC patients treated with regorafenib after sorafenib for the normal (≤60 U/L) and abnormal (>60 U/L) AST groups before 2nd-line treatment; (C) Kaplan-Meier curve of the PFS of HCC patients treated with regorafenib after sorafenib for the normal (≤60 U/L) and abnormal (>60 U/L) ALT groups before 2nd-line treatment. PFS, progression-free survival; HCC, hepatocellular carcinoma; AFP, alpha fetoprotein; AST, alanine transaminase; ALT, alanine transaminase.