Molecular therapies and precision medicine for hepatocellular carcinoma

Abstract

The global burden of hepatocellular carcinoma (HCC) is increasing and might soon surpass an annual incidence of 1 million cases. Genomic studies have established the landscape of molecular alterations in HCC; however, the most common mutations are not actionable, and only ~25% of tumours harbour potentially targetable drivers. Despite the fact that surveillance programmes lead to early diagnosis in 40–50% of patients, at a point when potentially curative treatments are applicable, almost half of all patients with HCC ultimately receive systemic therapies. Sorafenib was the first systemic therapy approved for patients with advanced-stage HCC, after a landmark study revealed an improvement in median overall survival from 8 to 11 months. New drugs — lenvatinib in the frontline and regorafenib, cabozantinib, and ramucirumab in the second line — have also been demonstrated to improve clinical outcomes, although the median overall survival remains ~1 year; thus, therapeutic breakthroughs are still needed. Immune-checkpoint inhibitors are now being incorporated into the HCC treatment armamentarium and combinations of molecularly targeted therapies with immunotherapies are emerging as tools to boost the immune response. Research on biomarkers of a response or primary resistance to immunotherapies is also advancing. Herein, we summarize the molecular targets and therapies for the management of HCC and discuss the advancements expected in the near future, including biomarker-driven treatments and immunotherapies.Molecular profiling studies are providing novel insights into the biology of hepatocellular carcinoma, although these remain to be translated into novel effective therapies. Nevertheless, therapeutic advances have been made in the past few years, and further advancements are expected in the near future, including biomarker-driven treatments and immunotherapies, as discussed in this Review.Key pointsThe global incidence of hepatocellular carcinoma (HCC) is increasing and might reach 1 million cases per year during the next decade.Next-generation sequencing studies have established the landscape of molecular aberrations associated with HCC; although the most common mutations (in the TERT promoter, CTNNB1, and TP53) are not clinically actionable, ~25% of HCCs harbour potentially targetable driver alterations.In phase III studies, survival benefits for patients with advanced-stage HCC have been demonstrated with five systemic therapies: sorafenib and lenvatinib in the first-line setting and regorafenib, cabozantinib, and ramucirumab in the second-line setting. Promising results have also been obtained with nivolumab in phase II studies in the second-line setting.Prolonging the outcome of patients with advanced-stage HCC to beyond 1 year is an unmet medical need; refining the identification of patients with tumours responsive or intrinsically resistant to immunotherapy and optimizing combinations with molecularly targeted therapies are major avenues for research.Proof-of-concept and biomarker-based trials of molecularly targeted agents should be implemented in both intermediate-stage and advanced-stage disease settings.