Pharmacogenetics of the systemic treatment in advanced hepatocellular carcinoma

Table 1 Published works on germ-line variants and pharmacokinetic and toxicity profiles of sorafenib in hepatocellular carcinoma patients

Pharmacogenetic panel	Study population	Therapy	Clinical endpoint	Main findings	Ref.
CYP3A4*1, CYP3A5*3, CYP2C19*2, CYP2D6*10	Advanced HCC (n = 51) (Chinese) Aflatoxin-induced HCC rat models (n = 105)	Sorafenib	Toxicity	Rat models: CYP3A4*1 (rs2740574) and CYP3A5*3 (rs776746) were associated with the lowest (8 ± 2.5ng/mL) and highest (67 ± 4.8 ng/mL) levels of sorafenib plasma concentration, respectively (P < 0.001); CYP3A5*3 correlated with the most severe liver (change in ALT and AST blood concentration [IU/L] over time) and renal injury (change in BUN [nmol/L) and Cr [umol/L] blood concentration [IU/L] over time) and CYP3A4*1 with the least severe injury (P < 0.001) Clinical setting: CYP3A5*3 was associated with increased severe hepatic toxicity (change in ALT and AST blood concentration [IU/L] over time, P < 0.001)	[32]
9 SNPs in CYP3A5, UGT1A9, ABCB1, ABCG2	Advanced solid cancer (n = 54; 37% HCC) (whites)	Sorafenib 400 or 200 mg, twice daily	PK Toxicity	UGT1A9 rs17868320-T allele was associated with increased grade ≥ 2 diarrhea (OR: 14.33, P = 0.015, multivariate analysis); ABCG2 rs2622604-TT genotype exhibited a greater exposure compared to the CC (sorafenib AUC, 131.8 vs 82.4 mg/L.h, P = 0.093 univariate analysis, not confirmed in multivariate)	[34]
8 SNPs in SLCO1B1, SLCO1B3, ABCC2, ABCG2, UGT1A1, UGT1A9	Advanced solid cancer (n = 114; 87% HCC) (mainly whites)	Sorafenib	Toxicity PFS OS	UGT1A1*28 (rs8175347) was associated with increased risk of acute hyperbilirubinemia (*28/*28 vs other, OR:5.413, P = 0.016) and of interrupting treatment (*28 vs other, OR: 3.397, P = 0.002) by multivariate analysis; the *28 allele also showed a trend towards a higher risk for any toxicity at grade 3 or higher (P = 0.088); SLCO1B1*1b (rs2306283-G) allele was associated with inferior risk of diarrhea (OR: 0.125, P = 0.007) and increased risk of hyperbilirubinemia (OR: 1.230, P = 0.002), and the SLCO1B1*5 (rs4149056-C) allele with higher risk of thrombocytopenia (OR: 4.219, P = 0.045) in univariate but not multivariate analysis; no SNP was associated with OS or PFS	[35]
49 SNPs in UGT1A9, UGT1A1, CYP3A4, CYP2B6, TNFA, VEGFA, IGF2, HIF1A	Intermediate stage HCC (n = 59) (Korean)	Sorafenib 400 mg twice daily in combination with TACE	Toxicity	VEGFA 1991-CC (OR: 45.68, P = 0.011), TNFA rs1800629-GG (OR:44.06, P = 0.023), and UGT1A9 rs7574296-AA (OR: 18.717, P = 0.015) were independent risk factors for the development of high-grade HFSR (multivariate analysis)	[36]
5 SNPs in ABCB1, ABCG2	Advanced HCC (n = 47) (Caucasians)	Sorafenib 400 mg twice daily	PK	ABCB1 rs2032582 (CT: 0.7 ± 0.6 kg/L vs TT:2.3 ± 2.2 kg/L, P = 0.035), ABCG2 rs2231137 (AG:0.8±0.4 kg/L vs GG:1.4 ± 1.5 kg/L, P = 0.02), ABCG2 rs2231142 (CA:0.5 ± 0.5 kg/L vs CC: 1.4 ± 1.4 kg/L, P = 0.007) heterozygous genotypes were associated with the lowest sorafenib plasma levels	[42]

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; AUC, area under the curve; BUN, blood urea nitrogen; Cr, creatinin; HCC, hepatocellular carcinoma; HFSR, hand–foot skin reaction; OR, odds ratio; OS, overall survival; PFS, progression-free survival; PK, pharmacokinetic; SNP, single nucleotide polymorphism; vs, versus.

Table 2 Published works on germ-line variants and response to sorafenib in hepatocellular carcinoma patients

Pharmacogenetic panel	Study population	Therapy	Clinicalendpoint	Main findings	Ref.
17 SNPs in VEGFA, VEGFC, FLT1 (VEGFR1), KDR (VEGFR2), FLT4 (VEGF3)	Advanced or intermediate-stage HCC (n = 148) (whites) (ALICE-1)	Sorafenib 400 mg, twice daily	PFS OS Objective Response	Univariate analysisVEGFA (rs25648-C, rs833061-T, rs699947-C, rs2010963-C), VEGFC (rs4604006-T), VEGFR1 (rs664393-G), and VEGFR2 (rs2071559-C, rs2305948-C) alleles were associated with longer PFS and OS; Multivariate analysisVEGFA rs2010963-C allele (PFS, 6.9 mo vs 4.0 mo, HR: 0.25, P = 0.0376; OS, 17.0 vs 9.3 mo, HR: 0.28, P = 0.0201), VEGFC rs4604006-T allele (PFS, 10.1 mo vs 4.3 mo, HR: 0.22, P = 0.004; OS, 22.0 mo vs 13.0 mo, HR: 0.25, P = 0.04) and BCLC C stage (PFS, 7.6 mo vs 4.5 mo, HR: 0.17, P = 0.0163; OS, 21.0 mo vs 10.7 mo, HR: 0.36, P = 0.0015) were independent prognostic factors predicting PFS and OS. Patients with both the favorable alleles of VEGFA rs2010963 and VEGFC rs4604006 showed improved PFS and OS compared to those with only one or none (PFS: P = 0.0004; two favorable alleles: 11.4 mo, one favorable and one unfavorable: 5.6 mo, two unfavorable: 3.4 mo; OS: P = 0.0001, two favorable alleles: 22.7 mo, one favorable and one unfavorable, 15.1 mo, two unfavorable, 8.8 mo). VEGFA rs2010963-C (P = 0.0343) and VEGFC rs4604006-T (P = 0.0028) alleles were also associated with a better objective response	[48]
18 SNPs in KDR (VEGFR2)	Advanced HCC (n = 78) (Chinese)	First-line sorafenib 400, mg twice daily	TTP OS Response	Univariate analysisVEGFR2 rs1870377-AA (5.8 mo vs 4.0 mo, P = 0.001) and rs2305948-AA (5.8 mo vs 4.5 mo, P = 0.016) genotypes were associated with longer TTP; VEGFR2 rs1870377-AA genotype (15.0 mo vs 9.6 mo, P = 0.001) and rs2071559-T allele (13.0 mo vs 9.0 mo, P = 0.007) were associated with longer OS; VEGFR2 rs1870377-AA (P = 0.011) and rs2305948-AA (P = 0.047) genotypes were associated with a better response; Multivariate analysis Major vascular invasion (HR: 2.51, P = 0.021) and VEGFR2 rs1870377-AA (HR: 0.68, P = 0.005) were independent factors in TTP; performance status (HR: 2.36, P = 0.017), VEGFR2 rs1870377-AA (HR: 0.35, P = 0.003) and rs2071559-CC (HR: 2.25, P = 0.036) were independent factors in OS	[50]
3 SNPs in eNOS	Advanced HCC (n = 41 training set; n = 87 validation set (whites)	First-line sorafenib 400 mg, twice daily	PFS OS	Univariate analysisTraining set Patients homozygous for the eNOSHT1 haplotype (HT1:T-4b by combining eNOS rs2070744 T>C and eNOS VNTR 27bp 4a/b** variants) had a lower median PFS (2.6 mo vs 5.8 mo, HR: 5.43, P < 0.0001) and OS (3.2 mo vs 14.6 mo, HR: 2.35 P = 0.024) than those with other haplotypes; Validation set Patients homozygous for HT1 had a lower median PFS (2.0 mo vs 6.7 mo, HR: 5.16, P < 0.0001) and OS (6.4 mo vs 18.0 mo, HR: 3.01, P < 0.0001) than those with other haplotypes; Multivariate analysiseNOS haplotype HT1 is confirmed as the only independent prognostic factor. ** “4a” allele with 4 repeats; “4b” allele with 5 repeats	[51]
9 SNP in ANG2	HCC (n = 158) (whites)	Sorafenib	PFS OS	ANG2 rs55633437-GG genotype was associated with a better PFS (median PFS: 4.67 mo vs 2.94 mo, P = 0.03) and OS (median OS: 16.9 mo vs 6.5 mo, P = 0.016) with respect to the T-allele; Data were confirmed in multivariate analysis	[52]
8 SNPs in HIF1A	HCC (n = 210) (whites) (ALICE-2)	Sorafenib	PFS OS	Univariate analysisHIF1A rs1951795, rs10873142, and rs12434438 emerged as significant predictors of PFS and OS; the extended analysis of VEGF/VEGFR SNPs confirms the results of ALICE-1 study (see above); Multivariate analysisHIF1A rs12434438, VEGFA rs2010963, and VEGFC rs4604006 were confirmed as independent prognostic factors. The combination of the favorable alleles of rs2010963 and rs4604006 compared to only one or to none, identifies three populations with different PFS (respectively: 10.8 mo vs 5.6 mo vs 3.7 mo, P < 0.0001) and OS (respectively: 19.0 mo vs 13.5 mo vs 7.5 mo, P < 0.0001). HIF1A rs12434438-GG genotype was associated with a poor outcome independently of VEGF markers (PFS: 2.6 mo, P < 0.0001; OS: 6.6 mo, P < 0.0001)	[49]

HCC: Hepatocellular carcinoma; HFSR: Hand–foot skin reaction; mo., months; OR: Odds ratio; OS: Overall survival; PFS: Progression-free survival; SNP: Single nucleotide polymorphism; TTP: Time to progression.

Table 3 Published works on germ-line variants and pharmacokinetics, toxicity, and efficacy of regorafenibin solid cancer patients

Pharmacogenetic panel	Study population	Therapy	Clinicalendpoint	Main findings	Ref.
3 SNPs in SLCO1B1, ABCG2	Advanced solid cancer (n = 37; no HCC) (Japanese)	Regorafenib	Toxicity	SLCO1B1*1b (rs2306283-G) allele was associated with lower incidences of increased grade ≥ 2 AST (8% vs 42%, P = 0.03) and anemia (16% vs 50%, P = 0.048); a similar tendency was observed for the incidence of increased grade ≥ 2 ALT (4% vs 25%, P = 0.09) and total bilirubin (12% vs 25%, P = 0.37); ABCG2 rs2231142 was associated with different blood platelet counts (Plt, CC: 29.4 ± 10.7 *104/μL, CA + AA: 21.4 ± 11.3*104/μL, P = 0.03)	[60]
3 SNPs in SLCO1B1, ABCG2	Advanced solid cancer (n = 28; no HCC) (Japanese)	Regorafenib	PK	SLCO1B1*5 (rs4149056-C) allele (17.3 [ng/mL]/mg vs 11.5 (ng/mL)/mg, P = 0.167) and SLCO1B1*1b (rs2306283-G/rs4149056-T) non-carriers (14.0 [ng/mL]/mg vs 12.1 (ng/Ml)/mg, P = 0.226) demonstrated a tendency toward higher concentration-to-dose ratio. Drug concentrations were higher in the group with grade ≥ 2 total bilirubin elevation (3.45 µg/mL vs 1.76 µg/mL, P = 0.01) and thrombocytopenia (3.45 µg/mL vs 1.76 µg/mL, P = 0.02) compared with the group with grades 0-1	[61]
Sequencing ofCYP34, UGT1A9	refractory mCRC (n = 93)1 (whites)	Regorafenib	Toxicity	UGT1A9*22 (rs383204-T10) allele was associated with acute hepatitis (descriptive study)	[57]
17 SNPs in VEGFA, VEGFC, FLT1 (VEGFR1), KDR (VEGFR2), FLT4 (VEGF3)	mCRC (n = 59) (whites)	Regorafenib	PFS OS DCR	Univariate analysisVEGFA rs2010963-CC vs to CG + GG genotype was associated with both longer OS (9.0 mo vs 6.5 mo, HR: 0.52, P = 0.049) and PFS (2.2 mo vs 1.8 mo, HR: 0.49, P = 0.0038); the same genotype was also associated with better DCR (progression rate, 47% vs 74%, P = 0.02); VEGFR2 rs1870377 (TT: 1.97 mo, AT: 1.84 mo, AA: 1.12 mo; P = 0.0061) and VEGFR3 rs307805 (AA: 1.91 mo, AG: 2.07 mo, GG: 2.3 mo; P = 0.0492) were associated with OS only; VEGFR1 rs664393 was associated with PFS only (CC: 2.01 mo, CT: 1.84 mo, TT: 1.48 mo; P < 0.0001); Multivariate analysisVEGFA rs2010963 (Exp(B): 2.77, P = 0.009) and ECOG performance status (Exp(B): 2.80, P = 0.004) were independent predictors of OS; the combination of these two parameters further stratified patients into three groups with progressively different OS (P < 0.0001); VEGFA rs2010963 was the only independent predictor of PFS (P = 0.005)	[63]
9 SNPs in CCL3, CCL4, CCL5, CCR5, PRKCD, KLF13, and HIF1A	mCRC (n = 79 Japanese patients–evaluation set; n = 150 Italian patients–validation set)	Regorafenib	PFS OS Toxicity	CCL4 rs1634517-CC and CCL3 rs1130371-GG were associated with longer PFS in the evaluation set (2.5 mo vs 2.0 mo, HR: 1.54, P = 0.043; 2.5 mo vs 2.0 mo, HR: 1.48, P = 0.064) and longer PFS (2.3 mo vs 1.8 mo, HR: 1.74, P < 0.001; 2.3 mo vs 1.8 mo, HR: 1.66, P = 0.002) and OS (7.9 mo vs 4.4 mo, HR: 1.65, P = 0.004; 7.9 mo vs 4.4 mo, HR: 1.65, P = 0.004) in the validation set; these associations were confirmed by multivariate analysis; in the evaluation set, the CCL5 rs2280789-GG genotype vs the A allele (12.9 mo vs 7.9 mo, HR: 0.45, P = 0.032) and the rs3817655-TT genotype respect to A allele (12.9 mo vs 7.9 mo, HR: 0.50, P = 0.055) was associated with longer OS by multivariate analysis; the analysis in the validation set was not possible because of the low SNP frequencies; in the evaluation set, the CCL5 rs2280789-GG genotype was associated with higher incidence of grade ≥ 3 HFRS compared to the A allele (53% vs 27%, P = 0.078), and similarly, the CCL5 rs3817655-TT genotype vs the A allele (56% vs 26%, P = 0.026); the same variants in addition to the CCL5 rs1799988 were also associated with different distribution by genotype of the incidence of grade ≥ 3 hypertension; in the validation set, the CCL5 rs2280789-G allele was associated with inferior incidence of grade ≥ 3 diarrhea vs AA genotype (0% vs 10%, P = 0.034) and KLF13 rs2241779-A allele with inferior incidence of grade ≥ 3 rash respect to CC genotype (10% vs 30%, P = 0.010); CCL3 rs1130371 and CCL4 rs1634517 were associated with different distributions by genotype of the incidence of grade ≥ 3 AST/ALT	[62]

¹Focused on 3 patients presented severe toxic hepatitis. ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; DCR: Disease control rate; HCC: Hepatocellular carcinoma; HFSR: Hand–foot skin reaction; mo., months; OR: Odds ratio; OS: Overall survival; PFS: Progression-free survival; PK: Pharmacokinetic; SNP: Single nucleotide polymorphism.