Department of Medicine, The Royal Marsden NHS Foundation Trust, Fulham Road, SW3 6JJ, London, UK.
Centre for Haematology, Imperial College London, Hammersmith Campus, Du Cane Road, W12 0NN, London, United Kingdom.
Department of Medical Microbiology and Immunology, Taibah University, Janadah Bin Umayyah Road, 42353, Medina, Saudi Arabia.
Department of Surgery& Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS, London, UK.
After a decade of stagnation in drug development, therapeutic reversal of immune-exhaustion with immune checkpoint inhibitors (ICPI) has been shown to be effective in advanced hepatocellular carcinoma (HCC). The clinical development of novel ICPIs continues at a rapid pace, with more than 50 clinical trials of immunotherapeutic agents registered as of May 2018 for this indication. The development of ICPI is particularly challenging in patients with HCC, a population with unique features which impact on safety and efficacy of immune-modulating therapies. In this review, we discuss the biologic foundations supporting the development of ICPI across the advancing stages of HCC, focusing in particular on the proposal of a rational positioning of ICPI across the various Barcelona-Clinic Liver Cancer stages of the disease. Translational studies should guide adequate prioritisation of those therapeutic agents and combination strategies which are most likely to achieve patient benefit based on solid mechanistic and clinical justifications.