Identification of Potential Predictors of Prognosis and Sorafenib-Associated Survival Benefits in Patients with Hepatocellular Carcinoma after Transcatheter Arterial Chemoembolization

Round 1

Reviewer 1 Report

This is a simple straightforward case-control retrospective review to see the benefit of adding TI to TACE in unresectable HCC. The hypothesis, methods, results, and conclusions were reasonable. They were able to show OS advantage with the addition of TKI without any effect on PFS. Interestingly, blood VEGF levels were able to predict the response in TACE-treated HCCSs tumor size, and T bili levels were predictive of sorafenib response.

Please consider following to make the paper a better on

Simple Summary

-           Consider simplifying the language so non-medical personnel can understand it.

Introduction

-          Adding a table summarizing the current evidence on TACE/sorafenib (lines 68-90) would be helpful for the readers (THIS IS NOT A NECESSARY CHANGE).  

Method

-          Section 2.1

o   Can you clarify what determined the addition of TKI to TACE? Was it physician’s discretion?

o   There are differences in EASL and AASLD classifications for HCC. These are in PS and CP scores. Which system was used by the team is not clear.

-          The entire heading of section 2.4 should be in the same format.  

-          Section 2.5- as this is a retrospective study, were the sample obtained from a repository? This section gives the impression that this is a prospective study

Results  

-          Section 3.1: Median time between first TACE and initiating TKI would be a helpful statistic (if it available).

-          Section 3.2: a table with these results can be useful

-          Section 3.4: to avoid confusion. Consider adding the number of patients or N in table 2

-          Section 3.6: lines 288-290, p-value of the VEGF levels is not significant; please revise these lines to reflect this.

Discussion

-          Remove the word unfortunately in line 361

Tables and figures

-          Figures 2, 3, and 5 are too small to read. Consider using bigger ones.

-          Figure 3D and 3E – label the favorability at the bottom, e.g., favors TACE or TACE-Sorafenib  

 Reference

 

-          The references are not according to the journal. They should be at the end of the sentence and not in the middle.  

Author Response

Response to Reviewer 1 Comments

Thank you for your comments. Please see below, we detailed the point-by-point responses to the comments and concerns.

Point 1: Simple Summary

- Consider simplifying the language so non-medical personnel can understand it.

Response 1: Despite the number of words has not decreased obviously, we have modified the Simple Summary in easily intelligible language according to your requirement and revised it in the re-submitted manuscript. The details are as follows:

Some studies have shown that sorafenib could significantly prolong the overall survival of patients with unresectable hepatocellular carcinoma treated with transcatheter arterial chemoembolization (TACE). However, other studies revealed that patients had no access to sorafenib-related survival benefits after TACE. To identify the predictive biomarkers of therapeutic efficacy of sorafenib, we explored the potential predictive value of vascular endothelial growth factor (VEGF) and other clinical variables for survival benefits from sorafenib in patients treated with TACE previously. The results demonstrated that patients with tumor size>7cm, or total bilirubin≤17.3μmol/L showed significant survival benefits from sorafenib after TACE treatment compared with those with tumor size≤7cm, or total bilirubin>17.3μmol/L. Meanwhile, patients with VEGF>131.09pg/ml may obtain sorafenib-associated survival benefits after TACE when compared to those with VEGF≤131.09pg/ml, which needs further confirmation. The above-mentioned results are helpful to confirm the specific population who are sensitive to targeted therapy. (In page 1 line 20-31).

 

Point 2: Introduction

- Adding a table summarizing the current evidence on TACE/sorafenib (lines 68-90) would be helpful for the readers (THIS IS NOT A NECESSARY CHANGE).

Response 2: According to your requirements, we have summarized the conclusions of previous studies in the form of a table as follows and uploaded it as a supplementary material (Table S1). The detailed information can be found in page 2 lines 87.

Table S1 Comparison of survival outcomes between TACE-Sorafenib and TACE alone for unresectable HCC in previous studies
Studies	OS	PFS	TTP	Ref.
Zhu K et al., 2014.	Yes		Yes	[17]
Li J et al., 2015.	Yes		Yes	[18]
Geschwind JF et al., 2016.	Yes			[19]
Zhang X et al., 2017.	Yes		Yes	[20]
Cai R et al., 2017.	Yes			[21]
Li L et al., 2018.	No		Yes	[22]
Kudo M et al., 2020.	Uncertain	Yes		[23]
Lencioni R et al., 2016.	No		No	[24]
OS, overall survival; PFS, progression-free survival; TTP, time to progression.

 

Point 3: Method

Section 2.1

- Can you clarify what determined the addition of TKI to TACE? Was it physician’s discretion?

Response 3.1: According to the EASL Clinical Practice Guidelines (1), TACE was the only recommended standard treatment for intermediate-stage HCC (BCLC stage B), and sorafenib was the frontline treatment option for advanced HCC (BCLC stage C). However, based on the China liver cancer (CNLC) staging system (2), TACE-Sorafenib combination therapy was recommended in CNLC stage IIb patients (belongs to stage B in the BCLC system) because of the prolonged PFS that was reported in the TACTICS Trial. In addition, some studies have revealed a significant survival benefit in HCC patients with PVTT (equivalent to BCLC stage C) who received TACE (3-5), the TACE in combination with system therapy was also allowed in patients with advanced HCC, which are recognized as a contraindication for TACE in Western countries (2, 6).

In conclusion, based on the fact that all patients in our study were from China, and referring to the CNLC guideline, we recommended TACE plus sorafenib for patients with intermediate-stage or advanced unresectable HCC. However, a part of the patients refused to receive targeted therapy after TACE because of the high price of sorafenib or other reasons. Therefore, the final number of patients in the two groups that we obtained was on the basis of the comprehensive results of our treatment regimen and the patients’ desire.

[1] EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. Journal of hepatology. 2018;69(1):182-236. doi: 10.1016/j.jhep.2018.03.019.

[2] Xie DY, Ren ZG, Zhou J, Fan J, Gao Q. 2019 Chinese clinical guidelines for the management of hepatocellular carcinoma: updates and insights. Hepatobiliary surgery and nutrition. 2020;9(4):452-63. doi: 10.21037/hbsn-20-480.

[3] Pinter M, Hucke F, Graziadei I, Vogel W, Maieron A, Königsberg R, et al. Advanced-stage hepatocellular carcinoma: transarterial chemoembolization versus sorafenib. Radiology. 2012;263(2):590-9. doi: 10.1148/radiol.12111550.

[4] Chung GE, Lee JH, Kim HY, Hwang SY, Kim JS, Chung JW, et al. Transarterial chemoembolization can be safely performed in patients with hepatocellular carcinoma invading the main portal vein and may improve the overall survival. Radiology. 2011;258(2):627-34. doi: 10.1148/radiol.10101058.

[5] Luo J, Guo RP, Lai EC, Zhang YJ, Lau WY, Chen MS, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma with portal vein tumor thrombosis: a prospective comparative study. Annals of surgical oncology. 2011;18(2):413-20. doi: 10.1245/s10434-010-1321-8.

[6] Kudo M, Matsui O, Izumi N, Iijima H, Kadoya M, Imai Y, et al. JSH Consensus-Based Clinical Practice Guidelines for the Management of Hepatocellular Carcinoma: 2014 Update by the Liver Cancer Study Group of Japan. Liver cancer. 2014;3(3-4):458-68. doi: 10.1159/000343875.

 

- There are differences in EASL and AASLD classifications for HCC. These are in PS and CP scores. Which system was used by the team is not clear.

Response 3.2: We are extremely grateful for your kind and important comment and reminding. In our study, all classifications for patients with HCC were according EASL Clinical Practice Guidelines. We have added above content to the re-submitted manuscript. (In page 3 line 112-114).

 

Section 2.4

- The entire heading of section 2.4 should be in the same format.

Response 3.3: We are very sorry for such a low-level mistake and have revised it immediately. (In page 4 line 157).

 

Section 2.5

- As this is a retrospective study, were the sample obtained from a repository? This section gives the impression that this is a prospective study.

Response 3.4: Thank you very much for your kind and important reminding, to clearly show that our study was a retrospective study, we added the following sentence at the end of section 2.5:

All the laboratory and clinical information mentioned above were retrospectively collected from the electronic case system of patients. (In page 4 line 181-183).

 

Point 4: Results  

Section 3.1

- Median time between first TACE and initiating TKI would be a helpful statistic (if it available).

Response 4.1: Thank you for your suggestion. The raw data that we collected could answer your comments, after the statistical analysis, we demonstrated that the median time between first TACE and initial sorafenib treatment in the TACE-Sorafenib cohort was 4.8 days. We have added above content to the re-submitted manuscript. (In page 5 line 220-221).

 

Section 3.2

- A table with these results can be useful.

Response 4.2: According to your request, we have summarized and added the details of Section 3.2 in the form of a table (Table S2) to the re uploaded manuscript. (In page 7 line 237).

Table S2. The median OS, PFS, DCR, ORR in the TACE cohort and the TACE-Sorafenib cohort
	TACE cohort		T-S cohort		HR* (95%CI)	p value
Median OS (m)	10.1 (6.5-13.7)		22.8 (18.8-26.9)		0.454 (0.299-0.688)	<0.001
Median PFS (m)	8.4 (3.0-13.8)		8.6 (2.9-14.2)		1.089 (0.711-1.668)	0.695
DCR (%)	85.1		93.6		-	-
ORR (%)	55.4		70.2		-	-
T-S, TACE-Sorafenib; OS, overall survival; PFS, progression-free survival; DCR, disease control rate; ORR, objective response rate; HR*, TACE-Sorafenib cohort vs. TACE cohort.

 

Section 3.4:

- To avoid confusion. Consider adding the number of patients or N in table 2.

Response 4.3: Thank you for your kind and important reminding, we have added the number of patients (N) in Table 2. (In page 8 line 271).

 

Section 3.6:

- Lines 288-290, p-value of the VEGF levels is not significant; please revise these lines to reflect this.

Response 4.4: Thank you very much for your important comments. Here we want to express a trend toward survival benefits from sorafenib for patients with high VEGF levels compared with those with low VEGF levels. Although the p value of interaction analysis was greater than 0.05 (p for interaction=0.233), we could learn from Figure 5A and 5B that the OS of patients with high levels of VEGF was significantly prolonged after receiving TACE-Sorafenib, while patients with low levels of VEGF had no prolonged OS.

For the above reasons, we have revised the contents of lines 288 - 290 as follows: Although There was no significant interaction between the VEGF levels and treatment modality (p for interaction=0.233), we could learn from Figure 5A and 5B that the OS of patients with high levels of VEGF was significantly prolonged after receiving TACE-Sorafenib, while patients with low levels of VEGF had no prolonged OS. A larger sample size is needed to further verify the predictive value of VEGF in response to sorafenib treatment (In page 11 line 309-316). At the same time, we have also presented these contents in Simple Summary (In page 1 line 28-30), Abstract (In page 2 line 46-49) and Conclusion (In page 16 line 439-440).

In spite of this interpretation, we are ready to answer any further comments from you.

 

Point 5: Discussion

- Remove the word unfortunately in line 361.

Response 5: Thank you very much for your important comments. We have removed the word unfortunately in page 15 line 388.

 

Point 6: Tables and Figures

- Figures 2, 3, and 5 are too small to read. Consider using bigger ones.

- Figure 3D and 3E – label the favorability at the bottom, e.g., favors TACE or TACE-Sorafenib

Response 6: We sincerely apologize for any inconvenience caused to the manuscript review due to an oversight of the research team. We have enlarged the fonts in Figures 2, 3, 4 and 5 for ease of reading. (In page 8 line 250, page 10 line 276, page 11 line 303, page 14 line 329).

Furthermore, we have labelled the favorability at the bottom of Figure 3D and 3E. (page 11 line 303).

Point 7: Reference

- The references are not according to the journal. They should be at the end of the sentence and not in the middle.

Thank you for your kind and important reminding, according to your request, we have placed all the references at the end of the sentence in the manuscript. (In page 2 line 60-62, page 15 line 372).

Finally, thank you again for your time and effort in improving the quality of the manuscript and we look forward to your further comments and suggestions.

Author Response File: Author Response.docx

Reviewer 2 Report

The present study investigated the clinical significance of VEGF to predict the benefit the combination of sorafenib in the patients with hepatocellular carcinoma (HCC). Serological level of VEGF showed the significant relation to the survival of HCC patients. In addition, the serological level of VEGF might predict the survival benefit of sorafenib treatment. The reviewer considers the design of the present study is simple but a part of results is difficult to explain the true meaning. The reviewer would like to ask some queries to the authors as described below.

 

1.    The reviewer cannot understand why the results shown in Table 4 can be an evidence to find the predictive factor of benefit of sorafenib treatment. The reviewer would request to explain the meaning of data shown in Table 4, especially the way to evaluate the therapeutic effect of sorafenib treatment in the present study. On the other hand, even if the benefit of sorafenib treatment can be explained by those data in Table 4, the serological level of VEGF has no significance as a predictive factor of benefit of sorafenib treatment because there is no statistical significance. According to the data in Table 4, tumor size or total bilirubin can be more significant predictive factor of sorafenib treatment. The reviewer would request the authors’ indication regarding this comment.

2.    The reviewer cannot understand the method to decide the cut-off level of VEGF at 131.09 pg/ml. The description regarding the method should be added.

3.    The present study focused only the serological level of VEGF for discovering the predictive factor of sorafenib treatment. Is there any reason why the authors focused the level of VEGF, not the other growth factors?

4.    In Fig 2,3,4,5, it is difficult to read the contents. The reviewer recommends to enlarge the font size in each figure.

5.    There are typographical errors especially in the main text. Proofreading should be performed again.

Author Response

Response to Reviewer 2 Comments

Thank you for your comments. Please see below, we detailed the point-by-point responses to the comments and concerns.

 

Point 1: The reviewer cannot understand why the results shown in Table 4 can be an evidence to find the predictive factor of benefit of sorafenib treatment. The reviewer would request to explain the meaning of data shown in Table 4, especially the way to evaluate the therapeutic effect of sorafenib treatment in the present study. On the other hand, even if the benefit of sorafenib treatment can be explained by those data in Table 4, the serological level of VEGF has no significance as a predictive factor of benefit of sorafenib treatment because there is no statistical significance. According to the data in Table 4, tumor size or total bilirubin can be more significant predictive factor of sorafenib treatment. The reviewer would request the authors’ indication regarding this comment.

Response 1: Thank you very much for your kind and important comments. In the present study, interaction analysis was performed to identify the predictive factor of benefit of sorafenib treatment, this approach is frequently used to find specific populations who are effective for a certain treatment.

The interaction can be simply understood as the effect of one factor on the outcome at various levels of another factor [1], or when the effect of a factor depends on the level of another factor, the two factors are said to be interacting [2]. In our study, the interaction can be understood as the difference of treatment modalities on survival of patients with HCC shows different results due to different levels of clinical variables.

For an example, from Figure 5C and 5D, we can learn that only when patients with tumor size>7cm, TACE-Sorafenib treatment could prolong the OS compared with TACE alone, that is to say, only these patients could obtain the survival benefits from sorafenib. While when patients with tumor size≤7cm, TACE-Sorafenib administration did not prolong the OS of patients compared with TACE alone, that is to say, these patients had no access to sorafenib-related benefits. The above explanation is also applicable to HCC patients with different total bilirubin levels.

The “p for interaction” in the Table 4 indicates the significance tests of interaction analysis. From the results of Table 4, we can see that there was a significant interaction between total bilirubin levels as well as tumor size and treatment modalities (p for interaction=0.031 and 0.004, respectively), however, there was no interaction between VEGF levels and treatment (p for interaction=0.233). But we could learn from Figure 5A and 5B that the OS of patients with high levels of VEGF was significantly prolonged after receiving TACE-Sorafenib, while patients with low levels of VEGF had no prolonged OS.

For the above reasons, we have revised the contents of lines 288 - 290 as follows: Although there was no significant interaction between the VEGF levels and treatment modality (p for interaction=0.233), we could learn from Figure 5A and 5B that the OS of patients with high levels of VEGF was significantly prolonged after receiving TACE-Sorafenib, while patients with low levels of VEGF had no prolonged OS. A larger sample size is needed to further verify the predictive value of VEGF in response to sorafenib treatment (In page 11 line 309-316). At the same time, the content in the (In page 1 line 28-30), Abstract (In page 2 line 46-49) and Conclusion (In page 16 line 439-440) has also been revised accordingly.

In conclusion, we used interaction analysis to confirmed the predictive factors for sorafenib-related benefits mainly referring to previous studies, which explored the potential predictors of survival benefits associated with sorafenib (sorafenib versus placebo) [3-4]. If the above explanation still fails to satisfy you, we look forward to your further comments and suggestions.

[1] Madurantakam PA, Rodriguez IA, Cost CP, Viswanathan R, Simpson DG, Beckman MJ, et al. Multiple factor interactions in biomimetic mineralization of electrospun scaffolds. Biomaterials. 2009;30(29):5456-64. doi: 10.1016/j.biomaterials.2009.06.043.

[2] Ahmad AL, Ismail S, Bhatia S. Optimization of coagulation-flocculation process for palm oil mill effluent using response surface methodology. Environmental science & technology. 2005;39(8):2828-34. doi: 10.1021/es0498080.

[3] Llovet JM, Peña CE, Lathia CD, Shan M, Meinhardt G, Bruix J. Plasma biomarkers as predictors of outcome in patients with advanced hepatocellular carcinoma. Clinical cancer research: an official journal of the American Association for Cancer Re-search. 2012;18(8):2290-300. doi: 10.1158/1078-0432.Ccr-11-2175.

[4] Bruix J, Cheng AL, Meinhardt G, Nakajima K, De Sanctis Y, Llovet J. Prognostic factors and predictors of sorafenib benefit in patients with hepatocellular carcinoma: Analysis of two phase III studies. Journal of hepatology. 2017;67(5):999-1008. doi: 10.1016/j.jhep.2017.06.026.

 

Point 2: The reviewer cannot understand the method to decide the cut-off level of VEGF at 131.09 pg/ml. The description regarding the method should be added.

Response 2: Thank you for your kind reminding, the method to decide the cut-off level of VEGF was described in the section 2.6. Statistical Analysis, according to your requirements, we have further explained relevant contents in Section 3.4 for your review. (In page 8 line 256-257)

 

Point 3: The present study focused only the serological level of VEGF for discovering the predictive factor of sorafenib treatment. Is there any reason why the authors focused the level of VEGF, not the other growth factors?

Response 3: It is mainly due to the following three reasons that we focused the serological level of VEGF for discovering the predictive factor of sorafenib treatment:

(i) There have been studies have confirmed that serum VEGF levels not only could independently affect the prognosis of patients with HCC [5] but also were closely associated with its proliferation and metastasis [6-7]. But few studies focus on the predictive value of VEGF on the efficacy of sorafenib.

(ii) A previous randomized controlled trial (RCT) [3] explored the prognostic value of serum VEGF and its predictive value for the sorafenib benefits in patients with advanced HCC (sorafenib versus placebo) and found that VEGF can independently influence the prognosis of HCC patients but failed to predict the survival benefits from sorafenib. Based on this fact, we tried to explore whether VEGF could predict the efficacy of sorafenib in patients treated with TACE previously (TACE-Sorafenib versus TACE alone).

(iii) At present, our hospital only has a kit for serum VEGF detection and we will continue to explore the predictive value of other factors such as FGF and PDGF whenever conditions allow.

[5] Lacin S, Yalcin S. The Prognostic Value of Circulating VEGF-A Level in Patients With Hepatocellular Cancer. Technology in cancer research & treatment. 2020;19:1533033820971677. doi: 10.1177/1533033820971677.

[6] Jinno K, Tanimizu M, Hyodo I, Nishikawa Y, Hosokawa Y, Doi T, et al. Circulating vascular endothelial growth factor (VEGF) is a possible tumor marker for metastasis in human hepatocellular carcinoma. Journal of gastroenterology. 1998;33(3):376-82. doi: 10.1007/s005350050099.

[7] Moon WS, Rhyu KH, Kang MJ, Lee DG, Yu HC, Yeum JH, et al. Overexpression of VEGF and angiopoietin 2: a key to high vascularity of hepatocellular carcinoma? Modern pathology: an official journal of the United States and Canadian Academy of Pathology, Inc. 2003;16(6):552-7. doi: 10.1097/01.Mp.0000071841.17900.69.

 

Point 4: In Fig 2,3,4,5, it is difficult to read the contents. The reviewer recommends to enlarge the font size in each figure.

Response 4: We sincerely apologize for any inconvenience caused to the manuscript review due to an oversight of the research team. We have enlarged the fonts in Figures 2, 3, 4 and 5 for ease of reading. (In page 8 line 250, page 10 line 276, page 11 line 303, page 14 line 329).

 

Point 5: There are typographical errors especially in the main text. Proofreading should be performed again.

Response 5: Once again, we would like to express sincere apologies for our mistakes. All typographical errors have been corrected for your review.

 

Finally, thank you again for your time and effort in improving the quality of the manuscript and we look forward to your further comments and suggestions.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

The reviewer would appreciate for the detailed responses from the authors. The reviewer has understood the authors’ comments and revisions.