Inclusion Criteria:
1. Diagnosis of HCC according to AASLD guidelines
2. Disease that is not amenable to a curative treatment (e.g. surgery, transplant,
radiofrequency ablation)
3. Prior treatment with immune check-point inhibitor (including anti-PD1, anti-CTLA4,
anti-PD1 plus anti-CTLA4, or above agents plus other targeted agents)
4. For patients who stop immune check-point inhibitor due to progressive disease, the
duration of immune check-point inhibitor must be 8 weeks or longer
5. Recovery to ≤ Grade 1 from toxicities related to any prior treatments, unless the
adverse events are clinically nonsignificant and/or stable on supportive therapy
6. Life expectancy of 12 weeks or longer
7. Age ≥ 18 years old
8. ECOG performance status of 0, 1 or 2
9. Adequate hematological function
1. Absolute neutrophil count (ANC) ≥ 1.2 x109/L
2. Platelets ≥ 60 x 109/L
3. Hemoglobin ≥ 8g/dL
10. Adequate renal function
1. serum creatinine ≤ 1.5 × upper limit of normal or calculated creatinine clearance
≥ 40 mL/min (using the Cockroft-Gault equation) AND
2. urine protein/creatinine ratio (UPCR) ≤ 1 mg/mg (≤ 113.1 mg/mmol) or 24-hour
urine protein < 1 g
11. Child-Pugh Score of A5 or 6
12. Total bilirubin ≤ 2 mg/dL (≤ 34.2 μmol/L)
13. Serum albumin > 2 g/dL (> 20 g/L)
14. Alanine aminotransferase (ALT) < 3.0 upper limit of normal (ULN)
15. Hemoglobin A1c (HbA1c) ≤ 8%
16. Antiviral therapy per local standard of care if active hepatitis B (HBV) infection
17. Capable of understanding and complying with the protocol requirements and signed
informed consent
18. Sexually active fertile subjects and their partners must agree to use medically
accepted methods of contraception (e.g., barrier methods, including male condom,
female condom, or diaphragm with spermicidal gel) during the course of the study and
for 4 months after the last dose of study treatment
19. Female subjects of childbearing potential must not be pregnant at screening.
Exclusion Criteria:
1. Fibrolamellar carcinoma or mixed hepatocellular cholangiocarcinoma
2. Prior cabozantinib treatment
3. More than two lines of systemic therapy (i.e. cabozantinib must be either 2nd line or
3rd line systemic treatment)
4. Known brain metastases or cranial epidural disease unless adequately treated with
radiotherapy and/or surgery (including radiosurgery) and stable for at least 3 months
before randomization.
5. Concurrent steroid use of prednisolone >10mg once daily
6. Presence of thrombosis or tumor invasion in inferior vena cava
7. Concomitant anticoagulation, at therapeutic doses, with anticoagulants such as
warfarin or warfarin-related agents, low molecular weight heparin (LMWH), thrombin or
coagulation factor X (FXa) inhibitors, or antiplatelet agents (eg, clopidogrel). Low
dose aspirin for cardioprotection (per local applicable guidelines), low-dose warfarin
(≤ 1 mg/day), and low dose LMWH are permitted.
8. The subject has uncontrolled, significant intercurrent or recent illness including,
but not limited to, the following conditions:
a. Cardiovascular disorders including i. Symptomatic congestive heart failure,
unstable angina pectoris, or serious cardiac arrhythmias ii. Uncontrolled hypertension
defined as sustained BP > 150 mm Hg systolic, or > 100 mm Hg diastolic despite optimal
antihypertensive treatment iii. Stroke (including TIA), myocardial infarction, or
other ischemic event within 6 months iv. Thromboembolic event within 3 months.
Subjects with thromboses of portal/hepatic vasculature attributed to underlying liver
disease and/or liver tumour are eligible b. Gastrointestinal (GI) disorders including
those associated with a high risk of perforation or fistula formation/bleeding: i.
Tumours invading the GI tract, active peptic ulcer disease, inflammatory bowel
disease, diverticulitis, cholecystitis, symptomatic cholangitis or appendicitis, acute
pancreatitis or acute obstruction of the pancreatic duct or common bile duct, or
gastric outlet obstruction ii. Abdominal fistula, GI perforation, bowel obstruction,
intra-abdominal abscess within 6 months
9. Major surgery within 2 months before randomization. Complete healing from major
surgery must have occurred 1 month before randomization. Complete healing from minor
surgery (eg, simple excision, tooth extraction) must have occurred at least 7 days
before registration. Subjects with clinically relevant co d. Cavitating pulmonary
lesion(s) or endobronchial disease
10. Lesion invading a major blood vessel (eg, pulmonary artery or aorta)
11. Clinically significant bleeding risk including the following within 3 months of
registration: hematuria, hematemesis, hemoptysis of >0.5 teaspoon (>2.5 mL) of red
blood, or other signs indicative of pulmonary hemorrhage, or history of other
significant bleeding if not due to reversible external factors
12. Subjects with untreated or incompletely treated varices with bleeding or high risk for
bleeding are excluded with the following clarification: subjects with history of prior
variceal bleeding must have been treated with adequate endoscopic therapy without any
evidence of recurrent bleeding for at least 6 months prior to study entry and must be
stable on optimal medical management (e.g. non-selective beta blocker, proton pump
inhibitor) at study entry.
13. Moderate or severe ascites (Radiologically detected but clinically insignificant
ascites is allowed)
14. Corrected QT interval calculated by the Fridericia formula (QTcF) > 500 ms within 21
days of registration Note: If the QTcF is > 500 ms in first ECG, a total of 3 ECGs
should be performed. If the average of these 3 consecutive results for QTcF is ≤ 500
ms, the subject meets eligibility in this regard.
15. Previously identified allergy or hypersensitivity to components of the study treatment
formulations
16. Pregnant or lactating females
17. Diagnosis of another malignancy within 2 years before randomization, except for
superficial skin cancers, or localized, low-grade tumors deemed cured and not treated
with systemic therapy
18. Other clinically significant disorders that are judged by investigators to be
unsuitable for the clinical trial
