| Eligibility |
Inclusion Criteria:
- FOR ARM 1 AND 2: Subjects with advanced hepatocellular carcinoma (HCC) with no
curative option; for Arm 2 subjects that are HCV-positive with genotype 1 or 4 virus
infection will be enrolled
- Be willing and able to provide written informed consent for the trial; the subject may
also provide consent for Future Biomedical Research (FBR); however, the subject may
participate in the main trial without participating in FBR.
- Have histologically or cytologically documented HCC (documentation of original biopsy
for diagnosis is acceptable if tumor tissue is unavailable) or clinical diagnosis by
American Association for the Study of Liver Diseases (AASLD) criteria in cirrhotic
subjects is required; for subjects without cirrhosis histological confirmation is
mandatory
- FOR ARM A AND B: Have Barcelona Clinic Liver Cancer (BCLC) stage C disease or BCLC
stage B disease not amenable to locoregional therapy or refractory to locoregional
therapy, and not amenable to a curative treatment approach
- Have a Child-Pugh A liver score at screening or within 14 days of first dose of study
drug
- Have a predicted life expectancy of greater than 3 months
- Have measurable disease based on RECIST 1.1 as confirmed by the blinded MD Anderson
radiology; target lesions situated in a previously irradiated area are considered
measurable if progression has been demonstrated in such lesions; Note: the same image
acquisition and processing parameters should be used throughout the study for a given
subject
- Have a performance status of 0 or 1 using the Eastern Cooperative Oncology Group
(ECOG) performance scale within 7 days of first dose of study drug
- Have documented objective radiographic progression after stopping treatment with
sorafenib or else intolerance to sorafenib; intolerance to sorafenib is defined as:
Common Terminology Criteria for Adverse Events (CTCAE) grade >= 2 drug-related adverse
event(s) which both a) persisted in spite of comprehensive supportive therapy
according to institutional standards and b) persisted or recurred after sorafenib
treatment interruption of at least 7 days and dose reduction by one dose level;
patients treated on sorafenib as the last treatment may start pembrolizumab at least
14 days after the last dose of sorafenib
- FOR ARM B: Subjects with chronic infection by HCV who are treated or untreated are
allowed on study; subjects with a past or resolved hepatitis B virus (HBV) infection,
defined as having a negative hepatitis B surface antigen (HBsAg) test and a positive
total hepatitis B core antibody (HBcAb) test and negative HBV deoxyribonucleic acid
(DNA) test at screening, are eligible for the study
- Have a negative urine or serum pregnancy test within 72 hours prior to receiving the
first dose of study medication (cycle 1, day 1) (female subjects of childbearing
potential); if the urine test is positive or cannot be confirmed as negative, a serum
pregnancy test will be required
- Be willing to use an adequate method of contraception for the course of the study
through 120 days (Arm A) or 180 days (Arm B) after the last dose of study medication
(male and female subjects of childbearing potential; acceptable methods of
contraception are as follows: A) single method (one of the following is acceptable):
a) intrauterine device (IUD); b) vasectomy of a female subject's male partner; c)
contraceptive rod implanted into the skin B) combination method (requires use of two
of the following): a) diaphragm with spermicide (cannot be used in conjunction with
cervical cap/spermicide); c) cervical cap with spermicide (nulliparous women only); d)
contraceptive sponge (nulliparous women only); e) male condom or female condom (cannot
be used together); f) hormonal contraceptive: oral contraceptive pill
(estrogen/progestin pill or progestin-only pill), contraceptive skin patch, vaginal
contraceptive ring, or subcutaneous contraceptive injection; abstinence (relative to
heterosexual activity) can be used as the sole method of contraception if it is
consistently employed as the subject's preferred and usual lifestyle and if considered
acceptable by local regulatory agencies and Ethical Review Committees
(ERCs)/Institutional Review Boards (IRBs); periodic abstinence (e.g., calendar,
ovulation, sympto-thermal, post-ovulation methods, etc.) and withdrawal are not
acceptable methods of contraception; if a contraceptive method listed above is
restricted by local regulations/guidelines, then it does not qualify as an acceptable
method of contraception for subjects participating at sites in this country/region
- Absolute neutrophil count >= 1200/uL performed within 7 days of treatment initiation
- Platelets >= 60,000/uL performed within 7 days of treatment initiation
- Hemoglobin >= 8 g/dL without transfusion or erythropoietin (EPO) dependency within 7
days performed within 7 days of treatment initiation
- Creatinine OR measured or calculated creatinine clearance (glomerular filtration rate
[GFR] can also be used in place of creatinine or creatinine clearance) =< 1.5 x upper
limit of normal (ULN) OR >= 60 mL/min for subject with creatinine levels > 1.5 x
institutional ULN; Note: creatinine clearance should be calculated per institutional
standard performed within 7 days of treatment initiation
- Total bilirubin =< 2 mg/dL, or direct bilirubin =< ULN for those with total bilirubin
> 2 x ULN performed within 7 days of treatment initiation
- Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]) and
alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) =< 5 x
ULN performed within 7 days of treatment initiation
- Albumin >= 3 g/dL performed within 7 days of treatment initiation
- International normalized ration (INR) or prothrombin time (PT) activated partial
thromboplastin time (aPTT) =< 1.5 x ULN unless subject is receiving anticoagulant
therapy as long as PT or aPTT is within therapeutic range of intended use of
anticoagulants performed within 7 days of treatment initiation
- FOR ARM B: Have a detectable GT1, GT4, or HCV viral load TD(q) based on the Roche
COBAS AmpliPrep/COBAS TaqMan HCV Test, version (v)2.0 from a blood sample; HCV RNA
(10,000 IU/mL in peripheral blood) at the time of screening have documented chronic
HCV GT1, GT4 (with no evidence of mixed genotype) infection: a. Positive for anti-HCV
antibody, HCV RNA, or any of the above HCV GTs at least 3 months before screening (HCV
RNA and HCV GT must be confirmed by screening lab results) OR b. Positive for anti-HCV
antibody or HCV RNA at the time of screening with a liver biopsy consistent with
chronic HCV infection (or a liver biopsy performed before enrollment with evidence of
chronic hepatitis C (CHC) disease, such as the presence of fibrosis) or a Fibroscan
performed within 12 months of day 1 of this study with a result of > 12.5 kPa or a
FibroSure (Fibrotest) performed during Screening with a score of > 0.75 and an
aspartate aminotransferase (AST): platelet ratio index (APRI) of > 2
- FOR ARM B: Subjects must undergo at screening HCV GT1a testing for resistance
polymorphism as per Zepatier labe
- FOR ARM B: Have liver disease staging assessment as follows: Cirrhosis is defined as
any one of the following: a. A liver biopsy performed prior to day 1 of this study
showing cirrhosis (F4) b. Fibroscan performed within 12 calendar months of day 1 of
this study showing cirrhosis with result > 12.5 kPa [29] c. A FibroSure (Fibrotest)
performed during screening with a score of > 0.75 and an AST: platelet ratio index
(APRI) of > 2; absence of cirrhosis is defined as any one of the following: a. Liver
biopsy performed within 24 months of day 1 of this study showing absence of cirrhosis
b. Fibroscan performed within 12 months of Day 1 of this study with a result of =<
12.5 kPa [29] c. A Fibrosure (Fibrotest) score of 0.48 and AST to Platelet Ratio Index
(APRI) of =< 1 during Screening Fibroscan cut-off of 12.5 kPa has a positive
predictive value of 90% and a sensitivity of 95% for >/= F3; based on box and whisker
plot of interquartile distribution > 12.5 kPa will exclude the majority of subjects
with metavir F3 fibrosis; in the absence of a definitive diagnosis of presence or
absence of cirrhosis by the above criteria, a liver biopsy is required; liver biopsy
results supersede the results obtained by Fibroscan or Fibrosure
- Subjecs in Arm B treated with ribavirin (RBV) must agree to double barrier birth
control from day 1 to 6 months following last dose of study therapy or they are
excluded from this trial
Exclusion Criteria:
- Is currently participating and receiving study therapy or has participated in a study
of an investigational agent and received study therapy, herbal/complementary oral or
IV medicine, or used an investigation device within 4 weeks of the first dose of
treatment; subjects must also have recovered from associated therapy (i.e., to grade
=< 1 or baseline) and from adverse events due to any prior therapy
- Has had esophageal or gastric variceal bleeding within the last 6 months; all subjects
will be screened for esophageal varices, unless such screening has been performed in
the past 12 months before first dose of treatment; if varices are present, they should
be treated according to institutional standards before starting study treatment
- Subjects with ALT > 5 x ULN at day 1 are not eligible for enrollment
- Subjects with total bilirubin > 2.0 mg/dL at day 1 are not eligible for enrollment
- Subjects with clinically apparent ascites or encephalopathy, or untreated varices are
not eligible for enrollment
- Portal vein invasion at the main portal branch (Vp4), inferior vena cava, or cardiac
involvement of HCC based on imaging
- Has had encephalopathy in the last 6 months; subjects on rifaximin or lactulose to
control their encephalopathy are not allowed
- Had a solid organ or hematologic transplant
- Had prior systemic therapy for HCC other than sorafenib, or intercurrent local therapy
to the liver tumor between sorafenib and study drug
- Has active autoimmune disease that has required systemic treatment in past 2 years
(i.e., with use of disease-modifying agents, corticosteroids, or immunosuppressive
drugs); replacement therapy (e.g., thyroxine, insulin, or physiologic corticosteroid
replacement therapy for adrenal or pituitary insufficiency, etc.) is not considered a
form of systemic treatment
- Has a diagnosis of immunodeficiency or is receiving systemic steroid therapy or any
other form of immunosuppressive therapy within 7 days prior to the first dose of trial
treatment; the use of physiologic doses of corticosteroids may be approved after
consultation with the sponsor
- Has received locoregional therapy to liver (transarterial chemoembolization [TACE],
transarterial embolization [TAE], radiation, radioembolization, or ablation) or
surgery to liver or other site within 6 weeks prior to the first dose of study drug;
minor surgery must have occurred at least 7 days prior to the first dose of study
treatment (cycle 1, day 1); subjects must have recovered adequately (i.e., grade =< 1
or baseline) from the toxicity and/or complications from any intervention prior to
starting therapy
- Has a known history of an additional malignancy, except if the participant has
undergone potentially curative therapy with no evidence of that disease recurrence for
5 years since initiation of that therapy
- Has radiographically detectable (even if asymptomatic and/or previously treated)
central nervous system (CNS) metastases and/or carcinomatous meningitis as assessed by
local site investigator and radiology review/CIV
- Has a history of (non-infectious) pneumonitis that required steroids or there is
current pneumonitis
- Has an active infection requiring systemic therapy
- Has a history or current evidence of any condition, therapy, or laboratory abnormality
that might confound the results of the trial, interfere with the subject's
participation for the full duration of the trial, or is not in the best interest of
the subject to participate, in the opinion of the treating investigator, including
dialysis
- Has known psychiatric or substance abuse disorders that would interfere with
cooperation with the requirements of the trial
- Is pregnant or breastfeeding, or expecting to conceive or father children within the
projected duration of the trial, starting with the screening visit through 120 days
after the last dose of trial treatment
- Has received prior immunotherapy including anti-PD-1, anti-PD-L1, or anti-PD-L2
agents, or if the subject has previously participated in Merck pembrolizumab clinical
trials
- Has a known history of human immunodeficiency virus (HIV) (HIV 1/2 antibodies)
- Has untreated active hepatitis B; Note: to qualify for enrollment, antiviral therapy
for HBV must be given for at least 3 months prior to first dose of study drug, and HBV
viral load must be less than 100 IU/mL prior to first dose of study drug; those on
active HBV therapy with viral loads under 100 IU/mL should stay on the same therapy
throughout study treatment; those subjects who are anti-HBc (+) and negative for
HBsAg, Anti-HBs, and HBV viral load do not require HBV prophylaxis, but need close
monitoring for reactivation
- Subjects who have received therapy for HCV =< 4 weeks from the start of pembrolizumab;
Note: those with untreated HCV and those who completed HCV therapy >= 4 weeks of study
treatment start are eligible
- Has dual infection with HBV/HCV or other hepatitis combinations at study entry
- Has received a live vaccine within 30 days of planned start of study therapy (cycle 1,
day 1); Note: the killed virus vaccines used for seasonal influenza vaccines for
injection are allowed; however intranasal influenza vaccines (e.g., FluMist) are live
attenuated vaccines and are not allowed
- Has received sorafenib within 14 days of first dose of study medication
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